A complete rupture of the rotator cuff tendons results in an inability to raise the arm away from the body. Most partial rotator cuff tears cause a vague pain in the shoulder area and may result in a "catching" sensation when the arm is moved.

Calcific Tendinitis

Sometimes tendinitis (inflammation of the tendon) and/or impingement leads to a build-up of calcium in the rotator cuff. The calcium deposits cause recurrent attacks of severe pain with intermittent aching.
   

Overuse Tendinitis

This condition is most commonly seen in swimmers and throwing athletes. It is occasionally associated with partial rotator cuff tears or impingement syndrome. Symptoms include pain aggravated by overhead or throwing motion and tenderness.
  

Labral Tears

Labral tissue can become caught between the glenoid socket and the head of the humerus, resulting in a labral tear. This flap of tissue moves in and out of the joint, causing pain and a catching sensation. Most labral tears are the result of an injury to the shoulder, such as falling on an outstretched arm. An unstable shoulder may also cause injury to the labrum if the humerus repeatedly dislocates out of the glenoid.
   

Adhesive Capsulitis/Frozen Shoulder

The cause of this condition is largely a mystery; however, it is known that it does not occur in any other joint in the body. One theory is that the condition may be an autoimmune reaction in which the body attacks the joint capsule causing an intense inflammatory reaction within the joint tissue. The shoulder "freezes" due to the severe inflammation. The loose tissue of the joint capsule that usually permits motion sticks together, limiting movement.

Frozen shoulder occurs in three phases, each lasting approximately four months. Initially, a "freezing phase" occurs, followed by a "frozen phase," and completed by a "thawing phase." The entire timeframe of a frozen shoulder may last as long as a year. Fortunately, it is very rare for the disorder to recur. Surprisingly, the non-dominant shoulder is affected more than the dominant one. This disorder usually occurs between the ages of 40 and 60, and 70% of the cases occur in women. It is not normally associated with calcium deposits or rotator cuff injuries, and often x-rays are completely normal.

Adhesive capsulitis sometimes begins following other injuries where the shoulder is immobilized because of the injury. A common example is a wrist fracture where the arm may be kept in a sling for several weeks. The condition can also begin while other shoulder problems are present. Sometimes bursitis, impingement syndrome, or a partial rotator cuff tear can lead to a frozen shoulder. The pain from the first condition may cause decreased use of the shoulder, and the underlying condition itself may lead to chronic inflammation. The combination of limited motion and inflammation sets the stage for the development of adhesive capsulitis. Usually, the adhesive capsulitis must be treated first to regain motion in the shoulder before the underlying problem can be addressed.
   

Acromioclavicular Joint Arthrosis/Osteoarthritis

The type of arthritis that occurs due to degeneration over time is called osteoarthritis. The acromioclavicular (AC) joint is a fairly common site for osteoarthritis in middle age. The symptoms of acromioclavicular (AC) joint arthrosis usually begin with pain and tenderness in the front of the shoulder around the joint. The pain may be worse when the arm is brought across the chest since this motion compresses the joint. The joint may also click or snap with movement.
   

AC Joint Separation

A shoulder separation is a dislocation of the acromioclavicular (AC) joint, the joint between the scapula and the clavicle. The AC joint can be injured to varying degrees:

• Type I: Partial tear of the AC ligament without change in position of the distal clavicle.

• Type II: Complete rupture of the AC ligament with a partial tear of the coracoclavicular ligaments. The distal end of the clavicle is displaced in relation to the acromion less than the full width of the clavicle itself.

• Type III: Complete rupture of both the AC ligament and the coracoclavicular ligaments with displacement of the distal clavicle.

The most common cause of an AC joint separation is a fall on the shoulder. As the shoulder strikes the ground, the force from the fall pushes the scapula down. The clavicle, because it is attached to the rib cage, cannot move down far enough to follow the motion of the scapula. Something has to give, and the ligaments around the AC joint begin to tear, dislocating the joint.
   

Shoulder Dislocation

Most shoulder dislocations (97 out of 100) are anterior, meaning that the humerus slips out of the front of the glenoid fossa. Dislocations generally result from a severe impact to the shoulder area and often require reduction by a physician. The dislocation is usually very obvious. Attempts at motion are painful and the shoulder looks abnormal. A dislocated shoulder may cause damage to blood vessels and the nerves around the shoulder joint, causing a patch of numbness on the outside of the arm. Several shoulder muscles may be slightly weak until the nerve recovers.
  

Shoulder Instability

Shoulder instability is a common problem after a shoulder dislocation. Instability means that the articulation between the humerus and the glenoid fossa remains excessively loose, and the humerus repeatedly slips out of the glenoid. If the shoulder slips completely out of the socket, it has become dislocated as discussed above. Repeated dislocations can cause further injury to the shoulder and lead to arthritis. In some cases, the shoulder slips partially out of position and then relocates. This condition is called subluxation.

Shoulder instability is commonly caused by an initial dislocation injury. The ligaments that are supposed to hold the shoulder in the socket may not heal properly, or they may remain stretched and too loose to keep the shoulder in the socket in certain positions. This situation can result in repeated episodes of dislocation even during normal activities.

Diagnostic and Surgical Procedures
   

Arthrogram

An arthrogram is performed to get a clearer picture of what is happening with the soft tissue structures of the shoulder. Dye is injected into the shoulder joint and x-rays are taken. In a shoulder with adhesive capsulitis, the radiologist will notice that not much dye can be injected into the shoulder joint - the capsule of the joint is contracted and, thus, smaller than normal. The x-rays taken after injecting the dye will show very little dye in the joint. If a tendon tear is present, dye will leak out of the shoulder joint at the site of the tear.
   

MRI Scan

Recently, MRI scans have been used more frequently to look at the tendons and ligaments of the shoulder. The MRI scan uses magnetic waves to create a series of "slice" images of the shoulder that show both bones as well as tendons and any torn areas.
   

Joint Manipulation

This procedure is done to promote healing in cases of adhesive capsulitis. With the patient under anesthesia, the physician stretches the joint capsule by putting the shoulder through a full range of motion. This action stretches the shoulder joint capsule and breaks up the scar tissue. It may be necessary to repeat this procedure several times to restore acceptable range of motion.
   

Arthroscopy

In shoulder arthroscopy, the surgeon makes three tiny nicks in the skin. Inserted into one nick is an arthroscope which allows full visualization of the shoulder’s internal joint structures. Through a second nick, the surgeon inserts miniature surgical instruments to smooth, clean, and repair the shoulder joint. An irrigation tube is inserted through the third nick, and a sterile saline solution is pumped through it.
  

Rotator Cuff Repair

Surgery to repair a rotator cuff tear is usually necessary for a complete rupture in the tendons resulting in an inability to raise the arm. Surgery may also be necessary for a partial tear if the tear causes more discomfort and weakness than the patient can tolerate. The timing of surgery is variable. In general, repair within three months of the injury results in a better outcome.

The surgery is usually done through a 4-5 inch incision in the side of the shoulder. In most cases, repairing the tendons involves first removing any degenerative rotator cuff tissue that does not appear healthy. Then, the humerus at the tear site is prepared for tendon reattachment. An area of soft tissue on the humerus is removed to form a raw bony area for attachment of the torn tendon. Drill holes are made in the humerus to allow placement of sutures through the bone to attach the tendon. The tear in the tendon is then sewn together. Other sutures are used to attach the tendons to the humerus by looping the sutures through the drill holes. The tendon heals to the bone over time and reattaches itself.

The arthroscope is extremely helpful when repairing rotator cuff tendons, but often it is necessary to add a "mini-open" procedure if the tendon is completely torn. Using the arthroscope at the beginning of the case allows visualization of the interior of the joint to facilitate trimming and removal of fragments of torn cuff tendon and biceps tendon. The next step utilizes the arthroscope to visualize and trim any bone spurs or thickened ligament beneath the acromion. If it is necessary to suture a complete rotator cuff rupture, a two-inch incision is made directly over the tear after it has been localized with an arthroscope. The deltoid muscle fibers are spread apart so that stitches can attach the rotator cuff to the bone. If the tear is retracted, small suture screw anchors may be used to reinforce the reattachment.
  

Impingement Surgery

The major goal of this procedure is to increase the space between the acromion and the rotator cuff tendons. First the surgeon removes any bone spurs under the acromion that are rubbing on the rotator cuff tendons and the bursa. Usually, a small part of the acromion is removed as well to give the tendons even more space and allow them to move without rubbing on the underside of the acromion.
   

Bankart Repair

Probably the most popular method for surgically stabilizing a chronically dislocating shoulder is a procedure known as a Bankart repair. This procedure was developed based on the idea that the primary reason the shoulder dislocates is that the ligaments in the front of the joint have been torn from their attachment on the glenoid. In this type of operation, the ligaments are sewn or stapled back into their original position and allowed to heal so that the shoulder is once again stable. Typically this operation is done through an incision on the front of the shoulder.
  

AC Joint Surgery

The procedure most commonly recommended for AC joint arthrosis is a resection arthroplasty, also called a partial claviculectomy. A resection arthroplasty involves removing the last half-inch of the clavicle. After removal of this piece of bone, scar tissue fills the space between the clavicle and the acromion to form a false joint. The end result is that a stable, flexible connection between the acromion and the clavicle is maintained. This procedure is usually done by making a small two-inch incision in the skin over the AC joint. In some cases, the surgery can be done using an arthroscope.
  

Surgical Treatment of Labral Tears

Surgical treatment for this condition is still evolving. The problem has not been recognized long enough to adequately evaluate the results of different treatments and surgical interventions. If the tear is small, arthroscopic excision of the torn tissue may be performed to eliminate pain and catching. If the tear is larger, the shoulder may also have a problem with instability. If this is the case, the labral tear may need to be repaired instead of simply removed. Several new techniques allow the surgeon to place small staples into the labrum via the arthroscope and attach the labrum to the bone of the glenoid. If the tear is too large to repair through an arthroscope, an incision is made in the front of the shoulder.
   

Total Shoulder Replacement/Shoulder Arthroplasty

In this procedure, the shoulder humeral head and glenoid are replaced with prosthetic joint components. The surgeon makes a large curved incision from the superior aspect of the acromion to the deltoid insertion. The anterior joint capsule is entered and the glenohumeral joint is dislocated. First, the humeral head is removed with a saw or osteotome, then the cartilage of the glenoid fossa is removed and a power drill is used to cut a hole for the fixation device of the glenoid component. Once the glenoid preparation is complete and the correct component size selected, acrylic cement is applied to the glenoid vault and the prosthesis is pushed into place and held until secure. Following placement of the glenoid component, the humeral head component is attached to the humerus and positioned appropriately into the new glenoid surface. The surgeon then puts the shoulder through a full range of motion to ensure functionality of the new joint, the operative site is irrigated, and the wound is closed in layers.

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Read the patient report(s) on our procedure practice page. Assign the appropriate codes and then compare your answers with our coding recommendations. Good luck!

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