Medial epicondylitis “Golfer’s Elbow” is a tendinosis (degeneration, not inflammation) of the tendon insertion at the elbow of the muscles that flex the wrist and pronate the forearm (turn the hand palm down). It is a very common condition, but not anywhere near as common at lateral epicondylitis or tennis elbow.

The most common symptoms of medial epicondylitis are a pain at the inside of the elbow when gripping, lifting or swinging a racket or stick for sport. This is what gives the condition its moniker. In addition, almost all patients will have pain at the bump on the inside of the elbow (medial epicondyle of the humerus).

The age range is similar to those with lateral epicondylitis at 35-65 years of age.  While tennis elbow is usually not caused by tennis, golfers’ elbow can in fact be caused by golf, especially if one’s swing needs “some work.” Other causes of the condition can be overuse with any type of lifting exercise, improper weight lifting (straight bar biceps curls), or sudden pulling with the wrist flexed. Patients often experience pain inside the elbow with use or activity.

It is important to remember that the condition is a result of tendon degeneration, not inflammation. For this reason, traditional anti-inflammatory medications do not work. These include NSAIDs and steroid injections. There are no definitive studies telling us what treatment works best.  In addition, most all treatments work the same as doing nothing. Therefore, we generally set patients up with a trial of physical therapy. Eccentric exercises and aggressive soft tissue mobilization set up by a trained therapist with a home program will usually decrease symptoms and allow the patient to return to sport. However, there is no need to wait for healing to return to sports or work either. We believe that if a patient will do the exercises before their activity, they will be able to perform better and without pain. The program should be incorporated as part of the warm-up. In rare cases, patients may need surgical treatment. The surgery is simple–but will require post-operative immobilization for 10-14 days followed by a supervised therapy regimen.

https://www.assh.org/handcare/condition/golf-injuries
https://orthoinfo.aaos.org/en/staying-healthy/golf-injury-prevention/

Golfer’s Elbow

The triceps is a tripinnate muscle, meaning it is made up of three parts–the long, medial, and lateral heads. It extends the elbow and allows the arm to be held in place in space. The triceps originates on the humerus and runs down the upper arm where it attaches to the olecranon process of the ulna. The triceps tendon can get tendonitis or suffer a frank rupture. Both can look similar. Furthermore, a rupture is often not ‘complete’ and can confuse the diagnosis.

Inflammation of the triceps as it inserts on the olecranon tip, which causes pain on the tip of the elbow and weakness. This inflammation is likely not an inflammatory state, but rather a degenerative one (like tennis elbow and golfer’s elbow).

Most often, males that participate in vigorous activity suffer from triceps tendon injuries. Common injury mechanisms include weight lifting, football, or heavy manual labor.  It is typically caused by an eccentric load on an outstretched arm.

Loss of extension strength of the elbow is helpful for diagnosis but is not always present. Often, the triceps is incompletely ruptured, and some extension is possible. An MRI or ultrasound will make a definitive diagnosis. In those individuals with less than a 50% rupture in children and the non-athlete, we can treat a rupture using physical therapy with excellent results. However, those with significant ruptures or athletes are generally treated with surgical repair.

Triceps Tendons Injuries

In general, arthritis describes joint destruction. Arthritis can be broken down into three broad types. Osteoarthritis (OA), which is the most common form, is when the smooth layer of cartilage breaks down and does not heal. Much less common than OA, inflammatory arthritis is an autoimmune attack on the cells that line the joints and tendons (synovial cells). Post-Traumatic arthritis is also called “wear and tear arthritis” as it occurs when persistent joint irregularities and joints remain unstable or loose and cause a loss of their cartilage.

The first symptom is typically a loss of motion, especially in extension. Patients report that they can’t “get their elbow out.” Pain at the end of flexion can also occur. Swelling, instability, and mechanical symptoms can also occur as the condition progresses. Numbness in the pinky and weakness in the hand can occur from compression of the ulnar nerve at the elbow.

Comprehensive arthritis care, NSAIDS, glucosamine, and elbow sleeves can all help the pain. Steroid injections can also help with the pain. However, none of these interventions will halt the progression of arthritis. Surgical therapies include arthroscopic or open capsule release and removal of loose bodies and heterotopic bone. They are aimed at increasing motion and decreasing symptoms. If these do not help, the ultimate surgical treatment for elbow arthritis is a total elbow replacement.

Elbow Arthritis

The radial head is the most proximal portion of the radius bone and is located on the outside or lateral aspect of the elbow. It is made up mostly of cartilage and acts as a secondary stabilizer to elbow stress.

Radial head fractures almost always result from a fall on an outstretched arm, when the forces impact the radial head and cause injury. Often there is an associated ligamentous injury. The worse the radial head fracture is, the more likely there is to be a ligament injury as well.

They can occur in kids as well as adults. Most commonly, they occur in postmenopausal women after a routine fall due to osteoporosis. Radial head fractures also happen with high energy falls (ice, stairs, ladders), where they often have other fractures or ligament injuries associated with them.

Radial head fractures are treated non-operatively or operatively. Individuals with a non-displaced fracture with NO BLOCK to motion or MECHANICAL symptoms can be treated in a sling. There is often a ligament injury associated with the fracture, so a slow increase in activity is required. Individuals with a block to motion or an articular step-off are treated surgically. If there are only one or two fragments to the fracture, it is reduced and fixed with screws. Often, the fracture is in too many pieces to ensure healing. In this case, it will be replaced with a metal end cap. This metal cap is called a radial head arthroplasty.

https://asht.org/sites/asht/files/docs/2022/Radial%20Head%20Fracture%202022.pdf

Radial Head Fractures

Lateral epicondylitis “Tennis Elbow” is an age-related pain phenomenon that exists at the lateral side of the elbow. The wrist extensor muscle, called the extensor carpi radialis brevis (ECRB), inserts on the lateral epicondyle of the elbow. This muscle stabilizes the wrist in extension and more importantly gives it the strength and stability necessary for a “power grip.” It is thought that degeneration or tearing of the tendon, either acutely or over time, at the attachment to the elbow bone is the cause of symptoms of lateral epicondylitis. However, the exact pathophysiology of symptoms is unknown.

One of the classic symptoms of lateral epicondylitis is pain with pressure on the bony prominence of the elbow. Lateral elbow pain with power grip and pain with wrist extension are also hallmarks of lateral epicondylitis. There is often pain with passive wrist flexion as well.

One of the most common questions we hear regarding lateral epicondylitis is “I don’t play tennis, why do I have tennis elbow?” You have to keep in mind that this nickname is just that, a nickname; the condition is by no means limited to people who play tennis! Lateral epicondylitis is most common in individuals between the ages of 35-65 years old, regardless of their activity level. Sometimes a patient will report a sudden increase in pain, or it can be a more insidious onset. Furthermore, lateral epicondylitis is thought to be an overuse injury, but the actual pathogenesis is not fully understood.

Even in the evidence-based literature, there are hundreds of papers studying different treatment modalities for lateral epicondylitis, but almost all treatment results are equal to placebo (in essence, doing nothing). This includes bracing; injections of blood, platelets, or bone marrow; shock wave treatment; ultrasound-guided methods, etc. We do know that steroid injections into the elbow are worse than doing nothing and anti-inflammatory medications won’t work because lateral epicondylitis is not an inflammatory condition.

https://asht.org/sites/asht/files/docs/2022/Tennis%20Elbow%202022.pdf
https://www.assh.org/handcare/condition/tennis-elbow-lateral-epicondylitis

Tennis Elbow

Radial Tunnel Syndrome, also known as radial neuritis, is a confusing and challenging condition affecting the terminal branch of the radial nerve in the arm, the posterior interosseous nerve.  It is often misdiagnosed as lateral epicondylitis (tennis elbow) due to the prevalence of that condition. However, this condition is a constriction or irritation of the posterior interosseous nerve in the proximal, lateral arm.

Pain in the proximal lateral forearm is the most common symptom of radial tunnel syndrome. There is usually not numbness associated with the condition.  Radial tunnel syndrome can occur at the same time as lateral epicondylitis, making the diagnosis more confusing. However, the pain is more distal, or toward the hand, than tennis elbow. There is pain with grip, activities and fine control of the fingers. We do not know definitively what causes radial tunnel syndrome, but we believe the posterior interosseous nerve is compressed at the proximal border of the supinator muscle.  This muscle has a thick, fibrous tendon-like border that the nerve must travel under, and as the band becomes thicker and therefore less compliant, it can cause constriction of the nerve. Some less common causes are ganglion cysts in the elbow and vascular malformations.

Patients are usually 35-65 years of age, and men and women are affected equally.  Radial tunnel syndrome can occur in tennis players and in golfers.  It also happens in those with true overuse conditions with repetitive wrist motion, especially rotation.

Generally, physical therapy works most of the time to treat radial tunnel syndrome.  Aggressive massage of the area combined with specific exercises will cure radial neuritis most of the time. Surgery is reserved for patients who do not get better with therapy or those with significant weakness, which is a sign of a much more severe compression.  Surgery consists of exploration of the nerve and release of the proximal supinator muscle. Some patients will get a temporary worsening of the weakness with surgery, but this almost always recovers.

Radial Tunnel Syndrome

Little Leaguer’s elbow is an injury to the growth plate on the inside of the elbow, which is known as the medial epicondyle. Growth plates are areas of long bones that are comprised of cartilage, the same soft tissue that makes up your nose and ears. This soft tissue is what ultimately allows for the longitudinal growth of bones as they develop and grow. Unfortunately, because it is made up of cartilage, the growth plate is the weakest part of a growing bone. In Little Leaguer’s elbow, stress to the medial elbow, or medial epicondylar growth plate, can cause injury.

The most common symptom of Little Leaguer’s elbow is elbow pain with a loss of velocity. The injury usually develops during an accelerated period of growth. Longer arms mean more torque, which, coupled with a weaker growth plate, can lead to damage. Therefore, any symptom of pain in a young thrower should result in cessation of pitching and rest. If the pain persists, then an evaluation by a trained orthopedic surgeon should be the next step.

Of course, to have an injury at the growth plate, one must be growing, so this injury typically occurs in young individuals who are rapidly developing. Overuse is thought to be the most common underlying cause of the injury; to that end, year-round baseball, playing for multiple teams, and not tracking pitch counts are the most common offenders. Most kids with this problem already know they are pitching and throwing too much, so they will often downplay their activity level. Once an individual stops growing, their growth plates close and are finally comprised of solid bone.  At this point, excess stress on the medial elbow will cause ligament damage known as a ‘Tommy John’ injury.   The most common age for Little Leaguer’s elbow is between 10-14 years old because most boys’ growth plates usually close by age 14, and they typically are not able to throw with enough velocity to cause an injury before age 10.

One word: education. With a better understanding of the pathology of this condition, we can stop the offending activities before they can cause injuries.  Pitch counts, rest, rotating pitchers, and regular evaluation of throwing mechanics are critical. However, it is essential to know that even if you do everything right, a young boy can still develop Little Leaguer’s elbow. Once a diagnosis of Little Leaguer’s elbow is made, we will generally cast the elbow because it is tough to keep a preteen boy from throwing. We have found that the most effective way to enforce rest is with a long arm cast. Return to play is usually six to eight weeks, but can be longer. After the resolution of symptoms, coaches and trainers should initiate a throwing program as the player slowly returns to sport. Once the player has returned to sport, the constant evaluation of throwing mechanics is essential to ensure that the injury does not persist.

Little Leaguer’s Elbow

A bursa is a fluid-filled sac that can be found in areas of the body that require the skin or tendons to glide. Common sites include the elbow (olecranon), the knee (patellar) and the shoulder (rotator cuff). Olecranon bursitis is the inflammation of the olecranon bursa. It is generally referred to as any swelling on the posterior elbow.

There are three primary causes of olecranon bursitis: trauma, inflammation, and infection. If the elbow is injured and there is bleeding in the bursa, olecranon bursitis can occur. Prolonged pressure from a traumatic event can also have the same effect. Second, patients with gout, rheumatoid arthritis or other inflammatory conditions can inflame the bursa and cause olecranon bursitis. Finally, an infection of the bursa will cause the sac to fill with fluid.

A non-infected bursa can be treated with the use of an elbow sleeve and, if necessary, an aspiration to remove excess fluid. Oftentimes, an aspiration is needed to diagnose infection or gout. A chronic bursa or one that has been infected before is usually treated with surgical excision. This requires patients to use a splint, followed by an elbow sleeve, for three to four weeks. In the case of an infected bursa, the infection must be controlled, which requires antibiotics and immobilization. In the case of a severe infection, this can require hospitalization and emergent surgery, combined with strong antibiotics.

https://www.assh.org/handcare/condition/olecranon-bursitis

Olecranon Bursitis

Cubital Tunnel Syndrome (CTS) is a compressive neuropathy of the ulnar nerve at the point behind the inside of the elbow where the nerve travels through the cubital tunnel. A compressive neuropathy is a progressive injury to a nerve caused by constant, unrelenting pressure; as the condition progresses, the outer covering of the nerve, which is called the myelin sheath, is injured due to a lack of blood flow. Small nerve fibers, those that conduct light touch and temperature, are affected first. Larger fibers, like those that conduct impulses to muscles, are affected later with chronic progression of the injury.

The most common presenting symptoms of cubital tunnel syndrome are numbness and tingling in the digits innervated by the ulnar nerve. These may be especially present at night time, often waking the sufferer up from sleep. Some people also complain of weakness, loss of dexterity, and a problem with consistently dropping objects.  Fine motor activities of the hand are also affected because the ulnar nerve controls all the small muscles of the hand. This can make typing and writing very difficult.

Cubital tunnel syndrome is often related to elbow position; to that end, sleeping with the elbow bent is the most likely culprit. Prolonged elbow flexion while typing or driving can also worsen symptoms. Like carpal tunnel syndrome, cubital tunnel syndrome often gets worse as individuals age and soft tissues become less compliant and less able to tolerate compression. Furthermore, people with diabetes, thyroid disorders, and obesity are more prone to compressive neuropathies. Finally, an estimated 10% of the population has a naturally subluxing ulnar nerve, which can be exacerbated by rapid elbow movements—like lifting weights, baseball, tennis—and this can cause symptom progression as well.

Mild cubital tunnel syndrome is treated with nighttime splinting and periodic reassessment to ensure there is no progression. The most reliable splint is an elbow pad or even a children’s knee pad worn backward so that the pad is anterior to the elbow. Either of these times, when worn while sleeping, can often relieve symptoms in mild compression on their own. However, in some cases, workplace and activity modification may also be required. Moderate and severe ulnar neuropathy is usually relegated to surgical treatment. One recent study done at Harvard demonstrated that severe ulnar neuropathy did improve with surgical treatment, but not to ultimately to normal levels. Therefore, surgical treatment before progression to severe disease is paramount. We treat patients surgically by releasing the nerve and placing it anterior to the elbow, allowing the nerve to be unaffected by the elbow position. Following surgery, patients are treated in a posterior elbow splint for two weeks. From week two to four they are relegated to limited activities but are encouraged to progress to activities as tolerated by four weeks post-op.

https://www.asht.org/sites/default/files/docs/2018/Cubital%20Tunnel%20Syndrome%202018.pdf
https://www.assh.org/handcare/condition/cubital-tunnel-syndrome

Cubital Tunnel Syndrome

The space between the top of the shoulder (the acromion) and rotator cuff tendon is known as the subacromial space. If pain occurs when the humerus is rotated inward it is known as shoulder impingement syndrome. When the arm moves to certain positions, the tendon and the bursa are pinched and trapped between the top of the acromion bone and the humerus bone. Shoulder impingement syndrome can cause micro tearing of the rotator cuff and gradual degeneration. Over time, impingement syndrome can progress to a full tear of the rotator cuff.

As a result, the tendons of the rotator cuff become inflamed. This condition can be caused by a number of things, including:

An injury during a motor vehicle accident

Playing sports that involve excessive overhead use of the shoulder, including swimming, weightlifting, tennis and baseball

Shoulder impingement is also known as swimmer’s shoulder, tennis shoulder and rotator cuff tendinitis.

The symptoms of shoulder impingement syndrome include one or several of the following:

Minor pain, which presents itself with both activity and rest

Pain that radiates from the front of the shoulder to the side of the arm

Sudden piercing pain with lifting and reaching movements

As shoulder impingement syndrome progresses, the symptoms tend to increase, and include:

Difficulty participating in activities that require the arm to be placed above the head or behind the back, such as combing the hair or putting on a jacket or shirt

The causes of shoulder impingement syndrome vary, and can include:

Repeated stress to the shoulder, which is caused by activities that involve throwing or raising the arm

Most commonly occurs in young athletes and the middle-aged. Athletes who participate in swimming, baseball, tennis, and weightlifting, and construction workers whose jobs involve repetitive lifting or constantly raising the arms above the head

Anatomical factors can also place a person at greater risk of developing this condition, such as the shape of the acromion or the degenerative changes that some people experience. Poor posture and weak or imbalanced shoulder musculature can also lead to impingement syndrome.

Initially, your doctor takes your full medical history and performs a physical examination. During the physical examination, you will be asked to:

Move your arm above your head and behind your back, on your own.

Relax your arm while your doctor moves your arm above your head and behind your back.

X-rays are routinely obtained and MRI scans are sometimes useful in diagnosing shoulder impingement syndrome, as these scans allow your doctor to rule out arthritis or rotator cuff tears as a cause of the pain and limited motion.

Non-surgical and surgical treatments can be used for impingement. The vast majority if shoulder impingement can be treated nonoperatively with PT to correct imbalances of the muscles around the shoulder, and occasionally steroid injections.

Non-steroidal anti-inflammatory medicines

Surgery may be recommended when non-surgical methods aren’t effective. Arthroscopic surgery performed by an orthopaedic surgeon is minimally invasive and re-creates space for the rotator cuff to move smoothly. Inflamed bursa that surround the rotator cuff tendon are also removed.

Generally, physical therapy is recommended during recovery from impingement surgery. After surgery, your arm may be placed in a sling to limit movement and provide support for a few days. A rehabilitation program will be recommended by your doctor, and will address your specific needs, and includes exercises that improve the range of motion and strengthen the arm. It usually takes between 6-12 weeks to completely heal.

Why does shoulder impingement hurt more at night?

Why shoulder impingement hurts more at night isn't completely understood. Inflammation could be part of the reason, which can occur when you hold your joint in one position for an extended period of time. When you hold your arm close to your body, you can restrict blood flow to your bursa and rotator cuff tendon.

Pain is sometimes associated with this position. When you're experiencing pain during the night, especially if you're a professional or high school athlete, it’s a definite red flag something's wrong, and you need to seek your doctor for expert care. However, even non-athletes can have shoulder impingements and experience pain.

Can shoulder impingement cause headaches?

Absolutely. Headaches could occur with shoulder and neck pain simultaneously. In fact, studies have shown that tension-type headaches often go along with increased tenderness in the shoulder and neck muscles.

When you have tender spots in your body's connective tissue or muscles, it's called "trigger points" and when touched, are painful. These trigger points may feel like knots, nodules or tight muscles.

Patients often describe the pain in tension-type headaches as a feeling of pressure in or around their head or like a band is tightening around their head. Research estimates up to 80 percent of adults have tension-type headaches. If you're experiencing these headaches with your shoulder impingement, Dr. O'Grady and his staff can help alleviate the pain they cause.

Where should I ice my shoulder impingement?

When you get any new muscle injury, your first step is to reduce the swelling, inflammation and pain associated with it. You may be tempted to use heat on your sore shoulder, but during the first seven days after you are injured, you'll want to use ice only. Ice helps reduce your inflammation, swelling and pain. Apply the ice to your skin for around 15 minutes; if needed, wrap the ice bag in a towel to avoid irritating the skin.

Will steroids or acupuncture help shoulder impingement?

Yes. While your orthopaedic surgeon at North Florida Bone & Joint Specialists treats most shoulder impingements with physical therapy, they do use steroid injections occasionally. Acupuncture may also help to manage pain and reduce inflammation if you have an acute shoulder impingement.

Yes. Taping helps align your shoulder back to its normal position and provide space for your injured structures to heal.

Shoulder Impingement

The shoulder is the most mobile joint in the body. Its ability to function properly relies on the strength of the muscles and ligaments that allow it to move. The rotator cuff is one of the most crucial components of the shoulder.

The rotator cuff enables the muscles to lift and rotate the bone of the upper arm (the humerus.) These muscles are located under the acromion – a part of the shoulder blade – and as such, are prone to damage. When the rotator cuff is damaged, it tears, and this tearing can cause extreme pain and compromise the strength of the shoulder, limiting the use of the shoulder and the entire arm.

A torn rotator cuff can result from a traumatic event, or it can tear slowly over time. The primary symptom of a torn rotator cuff is pain and reduced range of motion; however, other symptoms may present and can vary. Additional symptoms of a torn rotator cuff include:

Difficulty sleeping, especially when lying on the affected shoulder

Restricted motion and difficulty completing tasks that require reaching, such as combing your hair, or trying to scratch your back

Feelings of instability in the shoulder and/or arm

A torn rotator cuff can either be the result of a traumatic injury to the shoulder or can be caused by the progressive degeneration, (wear and tear) of the muscles. Common causes of a torn rotator cuff include:

The development of bone spurs around the shoulder blade

The following factors can increase the risk of a torn rotator cuff:

As you age, your risk of tearing your rotator cuff increases. This condition is most common in people over the age of 35.

Sports that require the use of repetitive arm motions can increase the chances of tearing the rotator cuff. These sports include but are not limited to, baseball, tennis, archery, golfing, and surfing, and basketball.

These types of jobs often require the use of repetitive, overhead arm movements, which can damage the rotator cuff. House painters, construction workers, and carpenters, for example, are susceptible to torn rotator cuffs. In addition, firefighters and law enforcement officers are also susceptible.

There may be a genetic component that can increase the chances of developing a torn rotator cuff. Individuals who have family members who have developed this condition may be more apt to develop it themselves.

Although x-rays and MRIs are extremely valuable diagnostic tools for identifying a torn rotator cuff, history and physical examination is by far the most valuable way to evaluate the cause of shoulder pain. This examination will allow the doctor to determine the cause of the pain, and also evaluate if it is coming from locations other than the shoulder, such as the neck or the heart.

When properly diagnosed, the majority of shoulder pain can be treated successfully without surgery. Although some rotator cuff tears need to be fixed, many of these can also be treated without surgery.

This may include altering the activities that the patient participates in, physical therapy, anti-inflammatory medications, and injections.

Arthroscopy is a minimally-invasive surgical treatment for a torn rotator cuff. Arthroscopic treatment of rotator cuff tears allows for a much more thorough evaluation of all of the structures of the shoulder. An experienced shoulder surgeon will be able to fix even the most complex rotator cuff tears arthroscopically.

Dr. O'Grady uses the latest surgical techniques and methods such as the Rotation Medical Rotator Cuff Repair System.

There are four phases of recovery in returning to activities and sports:

You may experience stiffness and tenderness during recovery, especially in the first phase, which will improve with strength training and physical therapy. During each phase of recovery, it is vital to listen to the aftercare instructions provided by your medical professional.

Can rotator cuff tears cause pain in other areas of the body?

While rotator cuff tear pain is primarily thought to be located in the injured shoulder, it can also radiate along the outside of your upper arm all the way down to the thumb in the case of a supraspinatus tendon injury, or down the back of the arm in the case of a subscapularis injury.

When the infraspinatus muscle is injured, you may feel pain deep in the shoulder joint all the way to the outer part of your arm and hand. In some cases, you may feel pain and tingling in your fingertips resulting from your rotator cuff injury. Dr. O’Grady and his staff at North Florida Bone & Joint Specialists will work with you to determine the scope and severity of your rotator cuff tear so you can make informed decisions about what your next move will be.

The long and short answer is: sometimes. Multiple variables go into determining the best course of action to maximize the success of the repair, these include age, severity and location of the tear, desired activity level, and much more. Dr. O’Grady and his staff are happy to discuss treatment options and statistical outcomes similar to your case to allow you to make an informed decision on your treatment plan.

There are non-surgical treatments that help relieve pain and improve function in the injured shoulder, including:

Physical therapy and exercises to strengthen your shoulder

Work with your orthopaedic surgeon to determine the best course of action for your rotator cuff tear and whether surgery could be beneficial. North Florida Bone & Joint Specialists utilizes cutting-edge technology and minimally invasive procedures whenever possible so you can feel confident that you are getting expert care and the best possible treatment.

What does a rotator cuff tear look like on MRI or X-ray?

When an x-ray of the shoulder is done, your rotator cuff tear may look like a small bone spur, or even appear completely normal. MRIs of the shoulder offer more detail and a bigger picture of the nature of the injury. MRIs allow the surgeon to determine the size of the tear, where the tear is in relation to the tendon, and the age of the tear.

When does a rotator cuff tear require surgery?

Not all rotator cuff injuries or tears require surgery. Your doctor may recommend surgery if you experience persistent weakness or pain in relation to your shoulder, limited use of your arm after months of conservative treatments, or limitations in daily activities. It is best to seek a consultation with an orthopaedic surgeon to determine the best course of action.

Why does a rotator cuff injury hurt at night?

Rotator cuff injuries irritate the small pocket sitting on top of the cuff called the bursa. This area typically becomes inflamed at night, resulting in severe pain that makes it difficult to sleep, which is instrumental in helping the body fight pain and repairing the damage from the tear.

Rotator Cuff Tear

A tendon is a cord that connects muscle to bone. Most tendinitis is a result of inflammation in the tendon. Generally, tendinitis is one of two types:

Acute: Excessive ball throwing or other overhead activities during work or sport can lead to acute tendinitis.

Chronic: Degenerative diseases like arthritis or repetitive wear and tear due to age can lead to chronic tendinitis.

The most commonly affected tendons in the shoulder are the four rotator cuff tendons and one of the biceps tendons. The rotator cuff is made up of four small muscles and their tendons that cover the head of your upper arm bone and keep it in the shoulder socket. Your rotator cuff helps provide shoulder motion and stability.

Treatment goals for shoulder tendinitis focus on reducing pain and inflammation in addition to preserving mobility while preventing disability and recurrence. The most common treatments may include resting the shoulder and wrapping it. Applying ice packs may also be appropriate for more recent or severe injuries. Over-the-counter medications such as Aspirin, naproxen and ibuprofen may be used to reduce swelling. Physical therapy, which includes range of motion exercises, may also be part of the treatment plan.

Because most cases of shoulder tendinitis are caused by overuse, preventative measures, as opposed to treatment, are preferred. This can be accomplished by:

Avoiding or modifying the activities that cause the problem. 

Correcting underlying conditions, such as improper posture or poor technique in sports or work.

Applying basic rules when performing activities, such as building up to your activity level, using limited force and repetition and stopping if unusual pain occurs.

Shoulder Tendonitis

What are the Types of Biceps Tendon Injuries at the Elbow?

The biceps tendon is a bipennate (two heads) tendon that attaches the biceps muscle to the radius in the forearm. Its main action is to supinate (forcefully rotate the palm up) and flex the elbow. Biceps tendonitis and complete biceps rupture are the two types of injuries. They are likely both part of the same disorder. The tendon insertion on the radius has a poor blood supply and therefore, may become injured through use or with age.

Inflammation, due to the body’s attempts at healing this tendon, can cause pain. Conversely, a frank rupture can occur. Sometimes there is a presenting period of pain in the anterior elbow before the tendon pops, but most of the time, it is just a sudden tear of the tendon.

Typically, weekend warriors get biceps ruptures. They are almost always male between the ages of 35-60. Steroids can also be implicated. Biceps tendonitis is less common or at least less diagnosed. These can be in men and women and present with anterior elbow pain, pain with lifting, and pain with gripping. There may or may not be an inciting injury.

A complete rupture is usually obvious if the tendon retracts up the arm. Often, a tight band of tissue in the arm prevents the tendon from retracting after the injury. There will be significant pain, swelling and often subcutaneous bleeding. An MRI is diagnostic. Tendonitis is diagnosed with a physical examination: pain with resisted supination, pain when pushing on the biceps tendon, and pain with resisted flexion. In addition,x-rays and MRIs are essential in making the diagnosis and ruling out other problems like radial nerve irritation.

Biceps ruptures are usually treated surgically. Non-surgical evaluations of patients show that not repairing a biceps tendon at the elbow can result in up to a 70% loss in supination strength and a 40% loss of elbow flexion strength. With the advent of new surgical techniques and hardware, surgeons can reattach the biceps through a drill hole in the bone with excellent results.

Chronic, long-standing biceps tendon ruptures can be treated surgically. While most orthopedic surgeons won’t treat a biceps tendon rupture after two to three weeks. We have treated patients as late as six years after injury. Ideally, we would treat patients earlier but sometimes they present late for a myriad of reasons. For chronic injuries, we use a tendon graft, either from the patient’s leg or more commonly from a tissue bank. The reason for surgical treatment late is continued pain or weakness. The cosmetic deformity may persist, but strength will improve.

Complications of surgical treatment increase with time from injury to surgery. This means time is of the essence for surgical treatment for acute ruptures.

https://orthoinfo.aaos.org/en/diseases--conditions/biceps-tendinitis/

Biceps Tendon Injuries

The shoulder is the most mobile joint in the human body. Because it is so flexible, the shoulder is highly susceptible to instability and injury. Acromioclavicular (AC) joint separation, more commonly known as a separated shoulder, is one of the most common shoulder injuries.

Acromioclavicular (AC) joint separation happens when the ligaments that attach the collarbone to the shoulder blade become injured or separated. The severity of this injury can range from mild to severe. In mild AC separation, the ligaments are stretched, while in severe cases, the ligaments are completely torn.

Acromioclavicular (AC) Joint Separation Symptoms

The symptoms of an AC separation vary, according to the severity of the condition. Symptoms can include:

Pain at the top of the shoulder, especially when moving the arm overhead, or while sleeping on the injured shoulder

The appearance of a bump on top of the shoulder blade

Weakness or instability in the arm or shoulder

The shoulder seems to hang lower than normal

There are several causes that can lead to the development of an AC separation. These causes include:

A hard fall, particularly when directly on the shoulder, which injures the ligaments that encircle and stabilize the AC joint

There are several factors that can increase your risk of developing an AC separation, including:

Playing football, hockey, or other contact sports

Participating in sports where falls are common, such as downhill skiing, gymnastic, volleyball or ice skating

The first step in diagnosing an AC separation involves discussing the history of the patient’s injury and a thorough evaluation of the patient's shoulder. During the initial examination, a medical care provider will assess the shoulder, looking for signs of a fracture or dislocation. The orthopaedic surgeon will also feel the bones and the soft tissue around the joint and between the clavicle and the acromion.

After the initial evaluation, the orthopaedic surgeon will further evaluate the patient’s condition, and this may include:

Taking X-rays, which can help the doctor determine whether the injury is a fracture or a separation. During an X-ray, the doctor may ask the patient to hold a weight in the hand of the affected shoulder. This will increase the deformity in the shoulder, making the injury easier to see on the X-ray.

Injecting a diagnostic anesthetic into the area, which can help to confirm the diagnosis and block any pain.

If a shoulder separation is found, it will be classified by the extent or the severity of the injuries. These classifications include:

Grade 1: This is a mild separation and generally involves a sprain of the AC ligament, which doesn’t move the clavicle and appears normal on X-rays.

Grade 2: The AC ligament is torn and the CC ligament is slightly torn or sprained, causing the clavicle to fall out of alignment to a degree.

Grade 3: This is a more severe separation and it occurs when the AC and CC ligaments are completely torn, putting the shoulder noticeably out of position.

Grades 4,5 and 6: These separations occur less commonly and usually involve more forceful injuries. The resulting deformity is typically obvious.

Both surgical and non-surgical methods can be used to treat an AC separation.

Non-surgical treatment includes:
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Surgical treatments are recommended for unstable AC joint separations, and include:
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The recovery process depends on the grade of the injury, and varies from patient to patient. The more minor injuries generally heal within weeks, while the more serious injuries may require surgical correction and take several months in order to restore normal function. Formal physical therapy is highly suggested to restore and rebuild strength, motion and flexibility.

In many cases, AC joint separation does not require surgery to heal. While surgery is sometimes a necessity, most patients recover well using more conservative treatments, such as anti-inflammatory medications, icing the shoulder to reduce swelling and pain, or stabilizing the arm in a sling for a couple of weeks.

Sometimes, taping is used as a means to reduce pain in the shoulder, provide support in the area, and promote faster healing. Physical therapy may be necessary once a certain level of healing has been accomplished. Dr. O’Grady and his staff encourage anyone with this type of injury to schedule an appointment and take advantage of the cutting-edge treatment options and expert care O’Grady Orthopedics has to offer.

There are a variety of symptoms related to AC separation injuries. They will vary according to the severity of the injury, the nature of how the injury occurred, and the pain tolerance of the individual.

Most people with AC joint separation will experience pain at the top of the shoulder. This pain may be exacerbated when you move your arm overhead or sleep on the injured shoulder. You may also experience weakness or instability in the affected shoulder or arm as well as limited mobility.

Some patients complain of bruising and swelling, popping noises when moving the shoulder, and one shoulder appearing to “hang” lower than the other.

Does AC joint separation require surgery?

AC joint separation is an injury that occurs with varying severity. As a result, there is a rating system that will determine the severity and most appropriate treatment for your AC separation injury. There are six grades assigned to AC joint separation with grades one through three representing less severe cases that can often be treated without surgery, though there are some instances when grade three AC joint separation requires surgery.

Grades four through six will almost always require surgery to repair the damage. In most cases, your orthopedic surgeon will work to reconstruct the ligaments. Sometimes pins or plates are used to promote stability in the area. Whenever possible, your surgeon will seek to use minimally invasive surgical techniques that do not require complete immobilization following the surgery and significantly reducing your recovery time.

AC joint separation injuries can be caused by a variety of factors, including falls, auto accidents, and sports injuries. Those who participate in contact sports, such as hockey or football, or sports where falls are common are at greater injury for AC joint separation.

Acromioclavicular Joint Separation

There are numerous types of arthritis; however, the form usually found in the AC joint is osteoarthritis (OA). The majority of arthritis cases involving the acromioclavicular joint are the result of previous trauma, infection, or wear-and-tear, all of which can lead to the development of OA.

Osteoarthritis is categorized as either primary or secondary. Primary OA refers to a generalized condition brought on by normal wear-and-tear that affects various joints throughout the body; whereas, secondary osteoarthritis refers to arthritis stemming from a previous trauma to the joint. Since injuries to the AC joint are common throughout the athletic society, secondary OA is frequently seen within the sports medicine community.

The pain associated with osteoarthritis is usually constant and localized to the affected joint. This pain may be caused by inflammation or muscle strains caused by impact to the shoulder.

Acromioclavicular Joint Arthritis

The biceps is located at the front of the upper arm. There are three biceps tendons. Two attach to the shoulder and one attaches to the elbow. The tendons function in the motion of both the elbow and the shoulder.

Biceps tendon tears can occur when the tendons are overused and exposed to repeated stress. This can cause a tendon to fray, and thus eventually tear. Tendons can also tear when there is an injury to this part of the arm, such as oddly moving or twisting the elbow or shoulder, or falling on an outstretched hand.

Bicep tendon tears can occur at either the shoulder or the elbow, and tears can be complete or partial. When a complete tear occurs, the tendon has torn away from the bone.

Sudden, severe pain in the upper part of the arm or at the elbow is the most obvious symptom of a biceps tendon tear. Additionally, a popping sound or sensation may be experienced when the tendon tears. Other signs of a biceps tendon tear include:

The appearance of a bruise on the upper arm

Difficulty rotating your forearm with the elbow bent

A change in the contour of the front of the arm

There are several causes and risk factors associated with a biceps tendon tear.

There are two main causes, which include:

Trauma – lifting an extremely heavy object that overpowers the muscle, or falling on an outstretched hand.

Overuse – Overuse wears down and frays the tendon, eventually leading to a tear. This occurs gradually, over time, and tends to occur naturally with age. Sports that involve repetitive throwing increase the possibility of a tear due to overuse. 

The following increases the risk of tearing the biceps tendon:

Age – It is more common in older people, as their biceps tendon has had more wear and tear

Heavy overhead activities – Lifting heavy objects over the head, such a s in weightlifting, can cause excess wear and tear on the tendon

Overuse of the shoulder – Overusing the shoulder in sports increases the risk of this condition. Swimmers, throwing athletes and tennis players often tear their biceps tendon

Corticosteroid medications – This can cause muscle and tendon weakness

Initially, your doctor will take a full medical history and conduct a physical examination. A physical examination is typically only effective for a complete rupture, as the deformity of the arm muscle is obvious. Your doctor may also ask you to bend your arm and tighten your biceps muscle. If you experience pain while doing so, this could indicate a partial rupture.

An MRI scan may also be ordered to diagnose a partial or complete rupture. X-rays may be useful to rule out other problems that is causing elbow and shoulder pain, although X-rays do not provide images of soft tissues, such as the biceps tendon.

Both non-surgical and surgical treatment methods are used for biceps tendon ruptures. Tears at the elbow most often require surgery, especially in active individuals. Because there are two attachments to the shoulder, a tear in the shoulder area if often well tolerated and can be treated without surgery.

Administration of nonsteroidal anti-inflammatory medications

Surgery is not always necessary for partial tears but may be recommended for very active adults. For complete tears, surgery by an orthopaedic surgeon is often necessary depending on the location. It is imperative to seek an early evaluation as surgery should be performed within two weeks for best results.

Recovery time varies from person to person. After surgery, you will wear a brace for four to six weeks. Rehab begins within the first 3 weeks and involves physical therapy and exercise. It’s also important to listen to the aftercare instructions provided by your doctor to prevent secondary injury.

Once a bicep is torn, it, unfortunately, will not reattach itself to the bone and heal on its own. There are, however, a variety of treatment options available depending on the severity of your injury and whether it was a partial or complete tear.

Dr. Roger Ostrander

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