Introduction

Achilles tendonitis is when the Achilles tendon becomes inflamed or irritated. This inflammation is often the result of a lot of stress on your calf muscles and Achilles tendon from either a sudden increase in intensity or frequency of exercise. Chronic overuse can contribute to micro-tears in the Achilles tendon, leading to wear and tear over time that weakens the tendon and thickening of the tendon from scar tissue.

When treated promptly, Achilles tendonitis is often short-lived. Left untreated, Achilles tendonitis can cause persistent pain or cause your tendon to rupture. The healing process causes scar tissue to form. Because scar tissue is not as elastic as the tendon, the scar tissue doesn’t allow the tendon to stretch normally, which can lead to a rupture of the tendon.

Fortunately, rest and over-the-counter medications to reduce your pain and inflammation may be all the treatment you need for Achilles tendonitis. In some cases, physical therapy may be needed. If you ignore symptoms, the result can be a rupture or tear of the tendon and surgery may be needed.

Where is the Achilles tendon and what does it do?

Tendons are strong, fibrous tissues that attach muscles to bones. When muscles contract, they pull on the tendon that moves the bone. The Achilles tendon attaches the two calf muscles (the outer gastrocnemius and the underlying soleus) that share the Achilles tendon to the heel bone (calcaneus). When contracted, the calf muscles pull on the Achilles tendon causing the foot to point downward helping you to rise up onto the ball of your foot. As the calf muscles relax, they allow you to lower your heel to the ground. This powerful muscle group in your calf helps you sprint, jump, or climb and provides the push-off phase in walking and running.

What causes Achilles tendonitis?

Achilles tendonitis is an overuse injury—doing too much too soon. Problems with the Achilles tendon affect athletes most often; especially runners, basketball players, and sports that require jumping—like volleyball and tennis. Problems are also common in middle-aged adults. Some injuries to the Achilles tendon are minor and some rather severe.

Achilles tendonitis can be either acute which occurs over a period of a few days following and increase in training, or chronic which occurs over a longer period of time. In athletes, problems are often acute following a sudden increase in training—either distance, speed or hills. Risk factors for non-athletes include diabetes, age, obesity, steroids, certain antibiotics or a “weekend warrior” injury.

What do Achilles tendon problems feel like?

Acute:

• Gradual onset of pain over a period of days
• Pain when exercise begins that gets better as the exercise progresses
• Pain gets better with rest
• Tenderness to pressure in the area

Chronic Achilles tendonitis can follow acute tendonitis if untreated. Chronic tendonitis is more difficult to treat.

• Gradual onset of pain over a period of weeks or months
• Pain with exercise that is constant throughout exercise
• Pain when walking up hill or up stairs
• Pain and stiffness in the tendon after rest and especially early in the morning
• Nodules or lumps in the tendon
• Tenderness with pressure
• Swelling or thickening of the tendon
• May have skin redness over the area
• May feel creaking when moving the ankle or pressing the tendon with your fingers

You can have pain either where the Achilles tendon attaches to the calf muscle—tendonitis—or where it attaches to the heel bone (calcaneus)—bursitis. There is a fluid filled sac between the tendon and the bone, called a bursa that limits friction when the tendon glides up and down at the back of the heel bone. Bursitis usually starts as pain and irritation at the back of the heel. You may see redness or swelling there. Shoes can aggravate the condition making it hard to wear shoes.

Tendonitis occurs just above the heel. Tendonitis is caused by a violent strain to the calf muscles or the tendon during a strong contraction of the muscle as when running or sprinting. This strain can occur where the muscles join the Achilles tendon. You will have pain when pressing on the Achilles tendon and with walking, especially when pushing off your toes or putting weight on your toes as when going down stairs or stepping off a curb.

How are Achilles tendon problems identified?

Diagnosis is done by your doctor taking a history—“what were you doing when the pain started?”—and a physical exam to see where your calf and/or foot hurt. You will likely have xrays to rule out fracture and identify bone spurs or other problems.

What are my treatment options?

Your treatment will depend on the severity of our injury and how long it has been since your injury. You will likely be started on rest, ice and anti-inflammatory medicines such as aspirin or NSAIDs.

Rest:

Resting the painful Achilles tendon allows the inflammation to subside and allow for healing. A period of rest—stopping the activity that is causing the pain—after the onset of symptoms is important in controlling Achilles tendonitis.

Immobilization:

In patients who have more significant symptoms, a period of immobilization can help. Either a removable walking boot, or sometimes even a cast, can allow the inflamed tissue to cool down quickly. Wearing a walking boot keeps the calf muscle from pulling on the Achilles tendon. The boot prevents you from pushing off with the ball of your foot or pointing your toes downward. The walking boot should be worn when walking. However, there is some benefit to wearing the boot even when you’re at rest as the boot keeps a slight stretch on the tendon and prevents further shortening.

Night Splint:

A night splint keeps the foot in a similar position as the walking boot, with a gentle stretch on the Achilles tendon. However, a night splint is not sturdy enough to allow walking. Daily use of a night splint while sedentary, from minutes to several hours, can assist physical therapy and continues the rehabilitation while at home. After recovery, a night splint can help prevent recurrent strains and maintains lower extremity flexibility, especially in athletes.

Physical Therapy

For some injuries, physical therapy is recommended to help remove or stretch scar tissue and to control pain and swelling. Patients with mild symptoms of bursitis or tendonitis often do well with two to four weeks of physical therapy. The physical therapist’s goal is to keep your pain and swelling under control, improve your range of motion and strength, and ensure you regain a normal walking pattern. Treatments such as ultrasound, moist heat, and massage are used to control pain and inflammation. As pain eases, treatment progresses to include stretching and strengthening exercise. Physical therapy can also include shockwaves, ultrasound, and ice. The key to proper ice and heat therapy is knowing when to ice and heat an injury. Your physical therapist knows when and how to apply treatment to reduce swelling and pain while still allowing the healing inflammatory process. Your therapist will teach you a home-care program to go along with the office therapy to help speed healing.

One purpose of the treatment is to break up scar tissue that has formed and to stretch out the scar tissue allowing the tendon to stretch normally without pain or tearing. The order of treatment is important. You don’t want to stretch a “cold” tendon. Injured tendons shorten and need to be stretched. Also, be careful not to overdo stretching. Only gentle stretches for the calf muscles and Achilles tendon are used at first. As the tendon heals and pain eases, more aggressive stretches are done. Ask your therapist, “On a scale of 1-10, how much should I be stretching the tendon.” To prevent further scar tissue from forming, ice is applied after stretching, massage, or treatments. Don’t overdo therapy as this can slow down the healing process by adding further injury to the tendon.

Ultrasound

Ultrasound—high or low frequency sound waves—can help increase the blood flow to the area to reduce swelling and speed healing. The vibrating sound waves can travel deep into the tissue (muscles) creating gentle heat. The heat increases the blood flow to the area to deliver oxygen and nutrients and remove cell wastes. The deep heat also helps relieve pain, inflammation and muscle spasms. Ultrasound is painless. You may feel tingling; often, you won’t feel anything at all.

Electrical Stimulation

Low-energy shock wave therapy has been used successfully for chronic tendonitis. This therapy does not require anesthesia and can take several treatment sessions. The vibrations produced by the energy waves are applied to the painful areas. Shock wave therapy stimulates soft-tissue healing by increasing blood supply to the treated area. Small electrode pads are placed on the painful area. Then you control the degree of “shock” to the area. The therapy can last as long as 20 minutes. During the treatment, you can increase the intensity as you adjust to each level. During treatment you should feel a tingling sensation, but not pain.

Electrical stimulation can also be used in iontophoresis. This treatment involves the application of a topical anti-inflammatory to the area. The stimulation forces the medication into the tissues reducing inflammation.

Steroid Injections

Steroid injections are rarely used because it is believed they can weaken the tendon increasing the risk of total rupture.

What to expect after treatment.

If you have mild symptoms, you should do well with 2-4 weeks of physical therapy; more severe injuries can take as long as 2-3 months. As your condition improves, you can begin doing exercises to strengthen your calf muscles. Strengthening starts gradually using exercises that work the calf muscles but protect the healing area. Eventually, you can do specialized strengthening exercises that work the calf muscle while it lengthens. For example, standing on your tiptoes and then carefully lowering your heels back to the ground.

When your healing is 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. You should be able to get back to normal activities. If you are an athlete, you will be guided through rehab specific to your sport.

It is important to properly rehab the tendon after you recover from the injury or the injury will return.

Gallbladder problems include:

• cholelithiasis (gallstones), where solid components of the bile form stones of various sizes. Gallstones can get in the bile duct, blocking the flow of bile causing swelling of the gallbladder and pain in the abdominal area. Cholelithiasis is associated with abdominal pain in the right upper quadrant all the way up to the right shoulder and may occur after fatty meal. Symptoms of jaundice may also accompany cholelithiasis. Gallstones are found in about 15% of men and 30% of women in the U.S.

• cholecystitis, which is the inflammation of the gallbladder due to infections. The most common symptoms of cholecystitis is sharp abdominal pain on the right side along with nausea, bloating, fever, vomiting and jaundice if gallstones are in the common bile duct. Cholecystitis can happen suddenly (acute) or over a longer period of time (chronic).

• perforated gallbladder is a condition where the gallbladder leaks or bursts. This happens rarely, but it can be life threatening.

Gallstones are usually diagnosed by ultrasound—a safe, painless, and non-invasive technique that uses high frequency sound waves to create an image of the gallbladder and gallstones. In order to relieve symptoms and complications, the gallbladder is removed surgically, called cholecystectomy.

Cholecystectomy Procedure

Cholecystectomy is the surgical removal of the gallbladder. More than 500,000 procedures are performed each year in the U.S. Cholecystectomy is usually done for gallstones and can be performed in two ways:
• open cholecystectomy
• laparoscopic cholecystectomy

Risks, Benefits, and Complications of Cholecystectomy

The benefit of having your gallbladder removed is relief of pain and most likely stop gallstones from coming back. If you don’t have gallbladder surgery, you risk the possibility of your symptoms getting worse, infection or the gallbladder bursting and infecting your abdominal cavity. Although there is some risk with all surgery, gallbladder removal is a very common surgery and the risks are small. Possible complications involved in open cholecystectomy are:
• bleeding
• injury to the common bile duct
• numbness
• raised scars
• hernia at the incision site
• puncture of the intestine
• wound infection
• abscess formation
• respiratory problems (pneumonia)
• deep vein thrombosis (blood clots)

Risks are lower with laparoscopic cholecystectomy. However, while inserting instruments and performing surgery, there is risk of injury to the common bile duct, which is the connection between the liver and the gallbladder. Minor injuries to the common bile duct are treated non-surgically, but major injuries can cause severe infection and pain and need corrective surgery.

Preparing for Cholecystectomy

Like any other surgical procedure, you will have to sign an informed consent that says you understand the procedure, its risks and potential complications and agree to have the surgery.

You shouldn’t have anything to eat or drink after midnight before the day of surgery. You can usually take your daily medicines on the morning of surgery with a sip of water. Talk to your surgeon before taking blood thinners that morning.

Anesthesia

Both surgical techniques are done under general anesthesia by a general surgeon. You will meet with the anesthesiologist before your operation. Be sure to let them know any problems you have had in the past with anesthesia or surgery. Also let them know if you:
• have any allergies
• have loose teeth or dental work
• have heart or lung disease
• have any health condition including stomach problems
• smoke, use alcohol or drugs
• take vitamins or supplements
• take daily medicines and what those are

With general anesthesia you will be asleep during the surgery and will not feel any pain.

What to Bring to the Hospital

• Insurance card and picture identification (driver’s license)
• Advance Directives
• Your glasses or dentures
• Loose fitting, comfortable clothes
• List of any medicines you take every day

Do not bring anything of value to the hospital such as jewelry, money, or electronics. The hospital will not be responsible if they are lost or stolen.

Prior to Cholecystectomy

You will get an ID bracelet on admission and taken to a presurgery area to change into a gown and have an IV placed in your arm or hand. The IV will be used to give you medicines and fluids. You may receive medicine to help you relax before they take you to surgery.

Open Cholecystectomy

This is the older procedure involving a 4 to 6 inch up-and-down incision in the right upper portion of the abdomen, or a slant incision just below the ribs on the right side. The peritoneum is cut and the gallbladder is removed. The incisions are then closed. In order to prevent accumulation of fluid at the incision site, drains may be used. The drain is usually removed in the hospital. The procedure takes about 1-2 hours. If there are no complications following surgery, you will be in the hospital for one to three days followed by 4 weeks’ rest at home before you can get back to your normal lifestyle. In more complicated cases, it may be 4 to 8 weeks before you get back to normal activity.

Laparoscopic Cholecystectomy

Laparoscopy – shows instruments in the abdomen

Laparoscopic cholecystectomy, often called “lap choly” is the latest procedure and is extensively used worldwide. During laparoscopic cholecystectomy, the surgeon makes four very small incisions (slits) of less than half an inch each. One slit is at the belly button, two are on the right side below the ribcage, and one is in the upper portion below the sternum, or breastbone. A tube is inserted into one of the slits and the abdominal cavity has been filled with carbon dioxide gas to inflate the area so the surgeon can see to work inside. A laparoscope is inserted in one of the other slits. A laparoscope is long tube with a small video camera and light on the end. This camera is connected to a video monitor, where the surgeon gets a good view of the organs and can perform the surgery accurately. The other incisions are used to insert various instruments to grasp and remove the gallbladder. The surgeon guides the laparoscope while watching the view it provides on a video monitor. The gallbladder is separated from the common bile duct and removed with a grasper tool through one of the incisions. Once the gallbladder is removed, the carbon dioxide gas is removed and all incisions are sutured or closed with tape strips. The procedure takes 1-2 hours.

In about 1 in 30 to 40 cases, the surgeon may start with laparoscopic surgery, but complications may cause the technique to be changed to open surgery. Complications include a severely diseased gallbladder, not being able to see the organs clearly, or the instruments cannot be used without risks. It’s important to know that even though you are expecting to have a laparoscopy, there is a chance of having an open cholecystectomy.

The need to convert from laparoscopic to open surgery is more common if:
• you are over age 65
• male
• have a history of acute cholecystitis
• have had prior abdominal surgery
• have a high fever or high bilirubin
• repeated gallbladder attacks
• other diseases that limit your activity

After Cholecystectomy

You will be taken to the recovery room until you wake up and are past any problems from the surgery. Careful attention is given in recovery as with any major surgery. Your blood pressure is monitored closely as well as your pulse, breathing and temperature.

Moving and deep breathing will help prevent fluid in your lungs and pneumonia. An effective way to breath deeply is to take a deep breath and hold it for 5 seconds. Take 5 to 10 deep breaths every hour while you are awake. Because of the anesthesia and not moving around, your risk of getting blood clots in your legs is increased. During surgery you may have had sequential compression stockings to help prevent blood clots. After surgery, it is important to get up as soon as possible and walk around to prevent blood clots.

It’s normal to feel tired for several days and you may need more sleep than usual. Don’t drive until your pain is under control without narcotics and your surgeon says it’s OK.

After Open Cholecystectomy

You may not be able to breathe deeply due to the effects of anesthesia or because of pain. Pain medications will be given to relieve pain. Be sure to let the nurses know if the pain medicine is not working. Controlling pain is very important; you want to feel like moving around and taking deep breaths, which will help prevent complications that can make your recovery take longer. Doing deep breathing exercises is very important in preventing pneumonia. The nurses will show you how to support to the incision with a pillow (splinting) while doing deep breathing exercises or coughing. Your incision site is checked for drainage and infection.

Your diet will start out as intravenous fluid and then slowly you will be given a regular diet as your bowel activity returns to normal and any nausea has stopped. It’s normal to have loose bowel movements for a few days after surgery. Pain medicine can cause constipation. If you are constipated increase the fiber in your diet or try a stool softener. Foods high in fiber include grains, fruits and beans.

You will go home in about 3-5 days. Slowly increase your activities. Do not lift of do any strenuous activity for 3-5 days. Returning to normal activities takes four to six weeks after surgery depending on your overall health and whether you had any complications.

Wound Care. Do not soak in a bathtub until your stitches or staples are removed and your wound has healed. It’s OK to take a shower unless your surgeon tells you not to. Protect the new skin of your incision from the sun as it can cause darker scarring; keep it out of the sun or wear sun screen for at least a year. Wear clothes that don’t rub against your incision. Change your bandages just as your surgeon prescribes and always wash your hands before and after touching near your incision site. Your scar will heal in about 4 to 6 weeks; it will get softer and fade over the next year. The feeling around your incision will come back in a few weeks or months.

After Laparoscopic Cholecystectomy

Pain from surgery can probably be controlled with pills. The abdominal pain can be accompanied with nausea and/or vomiting. Let the nurses know if you are nauseated; they can give you medicine to relieve the nausea. Liquids are OK to drink within 6 to 8 hours of surgery; solid food is allowed the day after the surgery. Pain medicine can cause constipation. If you are constipated increase the fiber in your diet or try a stool softener. Foods high in fiber include grains, fruits and beans.

Discharge from hospital is generally the same day. Slowly increase your activities. Do not lift of do any strenuous activity for 3-5 days. Returning to normal activities takes around 7 to 10 days. However, if you have other health conditions, you may have a longer hospital stay and a longer recovery period.

Wound Care. Do not soak in a bathtub until your steri-strips fall off (7-10 days) and your wound has healed. It’s OK to take a shower unless your surgeon tells you not to.

Biopsy

After the procedure, the gallbladder is sent for biopsy to confirm the diagnosis of either cholelithiasis or cholecystitis. The biopsy also helps to detect cancer. If cancer is detected, the patient might need to undergo another surgery to remove part of the liver or lymph nodes that are affected.

When to Call Your Surgeon

When you are discharged the nurses will tell you when to make an appointment for follow-up with your surgeon. Stitches or staples will be removed at follow-up. If you think you have a fever, take your temperature.

Prognosis

A small number of people are affected with post cholecystectomy syndrome, which has symptoms like gastrointestinal distress and/or constant pain in the right upper quadrant of the abdomen. Some others can develop chronic diarrhea after surgery. This can happen since the surgery causes disturbances in the bile duct. Most of the time no treatment is needed and clears up on its own within a few weeks. Many people have no symptoms at all after having their gallbladder removed.

Impingement of the rotator cuff is classified into three stages:
Stage I – initial inflammation and swelling
Stage II – tendonitis
Stage III – tearing of the rotator cuff

Shoulder Anatomy

The shoulder is not a single joint, but a complex arrangement of bones, ligaments, muscles, and tendons that is better called the shoulder girdle. The primary function of the shoulder girdle is to provide strength and range of motion to the arm. Learn more about the structure and function of the shoulder girdle.

The Subacromial Space

The subacromial space is beneath the acromion and above the rotator cuff. The subacromial bursa outlines this space and provides frictionless gliding of the rotator cuff beneath the arch formed by the acromion and coracoacromion. Bone spurs on the underside of the acromion are thought to narrow this space, irritate the bursa and contribute to tears in the rotator cuff.

12 Million people a year see their doctor for shoulder pain. About half of all shoulder injuries involve the rotator cuff.

Impingement occurs when the rotator cuff tendon and the bursa are pinched between the humerus and the front edge of the shoulder blade (acromion). As the arm is lifted, the acromion rubs, or “impinges” on, the surface of the rotator cuff causing pain and limiting movement. Impingement occurs during normal activity, but constant overhead use of the arm may result in irritation of the bursa and tendons. This leads to inflammation of the bursa, called bursitis. It can also lead to wear and tear on the rotator cuff tendons, called tendonitis. In some cases, a partial tear of the rotator cuff may cause impingement pain.

Inflammation of these soft tissues can cause swelling which reduces the amount of space between the acromion and the humeral head increasing the chances of developing bursitis. This space can also be reduced by bone spurs from the AC joint or variations in the anatomy of the acromion.

Risk Factors for Impingement Syndrome

People who do repetitive activities for sports (such as swimming, tennis, or baseball) or their job (painters, construction workers or paper hangers) are at risk for impingement.

Symptoms of Impingement Syndrome

The symptoms of bursitis and impingement on the rotator cuff include local swelling and aching in the front of the shoulder, that may radiate towards the neck and down to the elbow. Laying on the shoulder at night may be especially painful. Upward movement of the humerus, such as shrugging of the shoulder, can be very painful. Most people with rotator cuff symptoms complain of pain in the front of the shoulder and with overhead activities. Pain at night, stiffness and weakness are also common complaints. Advanced cases may progress to a frozen shoulder.

Diagnosis of Impingement Syndrome

The diagnosis of impingment and bursitis is usually made on the basis of the history and physical examination. Pain when performing the lift-off test indicates impingement. The lift-off test is done by resting the back of the hand of the affected arm on the lumbar spine area of the back. Then lift your hand off (away from) your back without straightening your elbow. If you can’t lift your hand that’s a positive test for impingement.

Xrays can only see bones and are used to confirm the presence of an abnormal acromion, or degeneration and spur formation in the acromioclavicular joint.

An MRI scan, arthrogram or ultrasound can be done to see the soft tissues of the joint and subacromial space. These test can show fluid or inflammation in the bursa and rotator cuff. An MRI may be ordered if there is a suspected tear of the rotator cuff tendons.

In some cases, an injection of a local anesthetic into the bursa can ensure the pain is actually coming from the shoulder and not radiating from the neck.

Treatment Impingement Syndrome

Intial treatment for impingement usually includes:
• resting the joint by avoiding overhead activities
• taking a mild anti-inflammatory medication
• stretching exercises to improve range of motion
• a physical therapy program for strengthening

If these measures fail to improve your pain, an injection of cortisone into the bursa may be done to reduce inflammation. Cortisone is a potent anti-inflammatory medication. It may bring the inflammation under control and ease your pain. Most patients have gradual improvement and a return of normal function. Treatment can take several weeks to months. There are special exercise that focus on rotator cuff recovery from injury.

If all conservative (non-surgical) measures fail, surgery may be required to remove the impingement by creating more space for the bursa and rotator cuff. Surgery for impingement usually begins by removing a portion of the acromion. Any bone spurs that appear to be rubbing on the bursa and tendons are removed and the coracoacromial ligament is cut to widen the space. This gives the tendons room to move without rubbing, and will decrease the pain and inflammation in the bursa and tendons.

In some cases opening up the subacromial space can be done arthroscopically, and you may be able to go home the same day. In other cases, an open incision is needed to remove the bone. An open incision may require a one or two night stay in the hospital. After surgery, the arm is in a sling for a short time to allow healing and support. A rehab program to regain strength and range of motion will be started based on what was found during surgery and the amount of repair needed. It takes about 2-4 months to get complete pain relief, but could take as long as a year.

The Appendix

The appendix is a 3-6 inch long, worm shaped process projecting from the end of the cecum and lined with a mucus membrane. The appendix is of no potential use to the functioning of the human body. The appendix is closed at one end and the other end is attached to the large intestine. The function of the large intestine is to move the waste from the body through the anus and also absorb water. The appendix might get blocked with stool or bacteria may cause it to produce mucus, which eventually thickens and blocks the appendix. When the appendix gets blocked, it gets swollen, inflamed and filled with pus. This condition is called appendicitis.

Symptoms of Appendicitis

The initial symptoms of appendicitis are on and off pain in right side of the abdomen, which gradually increases to a sharp and persistent pain in and around the bellybutton. The pain may move towards the right lower quadrant of the abdomen and gets worse with moving, taking a deep breath, coughing, sneezing, walking or being touched. Other symptoms include:
• fever (follows other symptoms) of 100°F to 101°F
• nausea, vomiting, loss of appetite
• frequent and/or painful urination
• diarrhea
• constipation, and can’t pass gas
• abdominal swelling in the later stages

Blood tests will show an elevated white blood count. Sometimes appendicitis can be hard to diagnose because many other illnesses cause sudden abdominal pain and similar symptoms. Early diagnosis is important to prevent rupture and complications.

If untreated, appendicitis can be fatal. When the infected appendix bursts, the contents of the lower gastrointestinal tract enters the abdominal cavity, and infects the entire peritoneal cavity. When this happens, the patient gets a high fever and the pain may suddenly stop.

Appendicitis is more common in males, occurs between the ages of 10 and 20, and rarely occurs after age 50. Acute appendicitis is an emergency and the appendix should be removed right away. There is no specific prevention for appendicitis.

Complications of Appendicitis

Complications of appendicitis include blocking of the intestine. When the appendix gets inflamed it can block the intestine and interferes with the function of the intestinal wall. This prevents passing of liquids and gas causing nausea and vomiting.

An infected appendix can rupture within 24 hours after symptoms begin. This may cause abscesses, that is, pus-filled boils around the appendix; or diffuse peritonitis, that is, the infection of the abdominal cavity which is a potentially life-threatening.

Appendicitis can also spread bacteria causing an infection in the blood stream—a life threatening illness called septicemia.

Diagnosis of Appendicitis

The initial diagnosis of appendicitis is done by a complete history and physical examination. The physical examination looks for signs of appendicitis like increased temperature, tenderness in the right lower portion of the abdomen, especially when the doctor presses on the area, there is a sharp increase in pain when the pressure is removed—rebound tenderness. To confirm the diagnosis of appendicitis, the doctor may order some or all of the following tests:

White Blood Count (WBC): The white blood cell count is usually elevated when an infection is present. An elevated WBC count helps confirm appendicitis. However, a WBC alone cannot determine appendicitis since a WBC increases in any kind of infection.

Urinalysis: This is the microscopic examination of the urine to determine the presence of red blood cells, white blood cells, or bacteria. An abnormal urinalysis means inflammation or kidney stones. The inflammation could be from the appendix since it is situated very close to the ureter and bladder.

Xray: Xray of the abdominal area can reveal an intestinal blockage. Stool may become hard and block the opening of the appendix which can be seen on xray.

Ultrasound: Ultrasound is a procedure that uses sound waves to examine various organs in the body. Ultrasound helps determine an enlarged appendix or abscess. Ultrasound also helps eliminate other health conditions that have symptoms similar to appendicitis, mostly in women, like complications of the ovaries or fallopian tubes.

CT Scan: A computerized tomography (CT) scan is very useful in case of pregnancy to identify appendicitis or other abscesses attached to the appendix and/or eliminate other diseases causing similar symptoms.

Anesthesia

Surgery can be done with either general anesthesia or spinal anesthesia.

Preparing for an Appendectomy

Preparations include the usual pre-surgery tests, including:
• complete blood count
• blood clotting tests
• urinalysis
• chest Xray

The anesthesiologist will want to know how long it’s been since you had something to eat or drink. General anesthesia can only be done on an empty stomach because of the risks of throwing up while sedated.

The Appendectomy Procedure

Appendectomy or removal of the appendix can be done in two ways—the traditional open surgery or the newer technique called laparoscopic surgery. The procedure takes about an hour.

In an open appendectomy, a two- to three-inch incision is made in the skin of the abdomen and underlying layer of fat. The muscles and organs are separated and the peritoneum is cut to reveal the cecum (part of the colon). The appendix and other abscesses, if any, are identified and cut away from the colon. Any fluid or pus from the infected appendix is suctioned away. Sometimes a drain is left in place for a few days. The colon is sutured and blood vessels are tied off; the abdominal cavity is closed, followed by suturing or stapling the incision made on the skin of the abdomen. Stitches or staples are usually removed 7-10 days after surgery.

Laparoscopy – shows instruments in the abdomen

In a laparoscopic appendectomy, there are no large skin incisions, only a few small puncture wounds. The laparoscope, which is a thin tube with a video camera attached at one end, is inserted through one of these puncture wounds. The doctor is able to see inside the abdomen on a TV monitor that is attached to the video camera. The camera allows the surgeon to verify the diagnosis before removing the appendix. The appendix is removed with instruments inserted through one of the other puncture wounds on the abdomen. Laparoscopy is better for the patient than open surgery because there is less postoperative pain and less chance of complications. If you have a laparoscopy, you will most likely go home on the day of your surgery.

Sometimes the surgeon is unable to identify the appendix with the laparoscope or unable to remove the appendix due to scar tissue from prior abdominal surgery. In this case, the surgeon will have to do an open surgery. Depending on what he finds, the surgeon may do the open surgery immediately or he may close the punctures and schedule the open surgery for a later date.

In some cases, the surgeon may find the appendix to be normal with no signs of appendicitis. The surgeon may decide to remove the normal appendix since it’s better to remove the appendix than to have appendicitis later.

After surgery you will go to the recovery for room about an hour. If you had an open appendectomy you will be up and walking around within 6 hours. If there are no complications you will go home in a day or two.

Complications of an Appendectomy

As with all surgery, an appendectomy has possible complications. Complications may be due to anesthesia, breathing problems, bowel obstruction, side effects to medicines or the surgery.

The possible complications from surgery are excessive bleeding or infection of the incision site. Infection can range from mild to moderate to severe. In mild infections, there is mild tenderness and redness in the area. Moderate infections can be treated with antibiotics; severe infections may require surgical procedures in addition to antibiotics. Infections are rare with laparoscopic procedures.

An appendectomy that was performed for a ruptured appendix can have other complications requiring a longer hospital stay.

In very rare cases, appendectomy can have long-term effects such as increasing the risks for other diseases like Crohn’s disease.

Post Appendectomy

After an uncomplicated appendectomy, you will be released from the hospital within three days and can resume normal activities in about 2-3 weeks. Returning to normal activities can be a little longer if the appendectomy was done for a ruptured appendix or there were complications. Care during the healing process includes:

Eating and Drinking: Start with a liquid diet if you have nausea and to allow your intestines to return to normal function. You can slowly resume your regular diet. It’s important to eat a balanced diet in order to speed up the healing process. You may need a stool softener to prevent constipation.

Incision Care: The incision should be kept clean and dry as prescribed by your surgeon. Do not get your incision wet in a tub or shower until your surgeon says it’s OK. If you think you have a fever take your temperature. Check your incision every day for signs of infection like increased redness, swelling, pain in the incision site, drainage, or fever above 101.5°F.

If you had open surgery, you will have a short scar; if your surgery was done laparoscopically, you will have 3-4 scars about a half inch long where the instruments were inserted into the abdomen.

Returning to Normal Activities: In most cases, you’ll be allowed to resume regular activities within two to three weeks after surgery. Your surgeon may give you certain restrictions to follow to avoid complications. Restrictions can include avoiding heavy lifting, not going to the gym, playing sports, running or jogging, or doing any heavy physical activities for 6 weeks. Avoid driving for 2 weeks.

Anatomy of the Shoulder

The shoulder is a ball-and-socket joint where the arm joins the upper part of the body. The ends of the two bones, the humerus (upper arm bone) and the scapula (shoulder blade) are covered by articular cartilage. The smooth surface of the articular cartilage makes movement of the joint easy and pain free. The shoulder joint (acromioclavicular joint) is held together by a group of muscles and tendons called the rotator cuff. A healthy rotator cuff keeps the ball of the humerus in the socket (glenoid) of the scapula and aids in the movement of the shoulder in many directions. Injury or disease of the rotator cuff from overuse, injury or trauma can cause pain and instability in the shoulder.

See Anatomy of the Shoulder for more details.

Shoulder Problems Diagnosed or Treated With Arthroscopy

Shoulder arthroscopy may be done to diagnose or treat the following:

Rotator Cuff Tear or Injury

Rotator cuff repair: The edges of the muscles are brought together. The tendon is attached to the bone with sutures. Small rivets (called suture anchors) are often used to help attach the tendon to the bone. The anchors can be made of metal or plastic. They do not need to be removed after surgery.

Shoulder Instability

Instability is when bony segments cannot maintain alignment due to torn or lax ligaments and weak muscles. Shoulder Instability is when the shoulder joint becomes loose and the joint dislocates—the ball slips out of the socket.

Surgery for shoulder instability: If you have a torn labrum, the rim of the shoulder joint that is made out of cartilage, your surgeon can repair it.

Labral or Ligament Tears

Shoulder arthroscopy is a commonly used for tears of a labrum, like a Bankart lesion or SLAP lesion, as well as ligament tears. Rehab after the arthroscopy for these problems play an important role in getting back to normal.

Shoulder Impingement Syndrome

Impingement syndrome is a condition where the rotator cuff tendons become inflamed at the subacromial space causing pain, weakness and loss of movement of the shoulder. Arthroscopic subacromial decompression (cleaning out the space under the acromion) removes the bursa (the fluid-filled sac near the shoulder joint) and other bony projections (bone spurs) that may be causing the irritation creating space for the tendons and helping reduce inflammation. Decompression is done when other conservative treatments don’t work.

Surgery for impingement syndrome: Damaged or inflamed tissue is cleaned out in the area above the shoulder joint itself. Your surgeon may also cut a specific ligament, called the coracoacromial ligament, and shave off the under part of a the acromion.

Frozen Shoulder

A frozen shoulder, called adhesive capsulitis, is a condition where the connective tissues surrounding the shoulder joint become inflamed causing pain and restricting the movement of the shoulder. Similar to impingement syndrome, arthroscopy for frozen shoulder is done only after conservative therapy doesn’t work. An arthroscopic procedure for a frozen shoulder should be immediately followed by physical therapy to reduce chances of the problem coming back.

Arthritis

Arthritis or inflammation of the joint, an arthroscopic procedure is performed to remove the damaged bone in order to regain normal movement of the shoulder joint. Shoulder arthroscopy may also be done to relieve the arm from problems related to arthritis like cartilage inflammation or tear, ligament rupture, or even when the joint surfaces become rough due to constant rubbing against each other.

Torn or Damaged Biceps Tendon

The biceps tendon becomes inflamed from impingement syndrome or rotator cuff tears. It can also become inflamed on its own. In order to relieve the symptoms of biceps tendonitis, an arthroscopic procedure called the biceps tenodesis is performed to anchor the tendons and prevent further problems.

Preparing for Shoulder Arthroscopy

Be sure to tell your surgeon about all prescription and non-prescription medicines you are taking, including alcohol, supplements, cigarettes, or herbs. Include the name, the amount and how often you take them. Ask your surgeon which medications you should take on the day of your surgery.

Two Weeks Before Surgery

To prepare shoulder arthroscopy you may need to get an urinalysis and blood tests. If you are over 50, you may also need an EKG, chest x-rays to make sure you’re OK for anesthesia. If you have other illnesses like diabetes, heart or lung disease, you will need clearance for the surgery from your regular doctor. If you take medications that cause thinning of the blood—like ibuprofen, aspirin, naproxen—you should stop taking these medicines about two weeks before your surgery.

If you are suffering from an illness like a cold, flu, fever, herpes or infection within a week of your surgery, tell your surgeon—your surgery many need to be postponed to prevent complications.

If you smoke, stop. Nicotine slows down the healing process for tissues and bone. Ask your ways to help you stop. Do not use nicotine patches to help you stop since you will still be getting nicotine. If you drink more than one or 2 drinks a day, be sure to tell your surgeon.

The Day of Surgery

Don’t eat or drink anything after midnight of the day of your surgery. Take the daily medicines with just a sip of water that your surgeon said it’s OK to take. Arrive at the hospital or surgical center on time.

Anesthesia for Shoulder Arthroscopy

Usually a combination of both regional anesthesia and general anesthesia is used. The regional anesthesia makes the arm and shoulder numb so you don’t feel any pain during surgery. General anesthesia puts you to sleep and is used to make you comfortable during surgery.

Shoulder Arthroscopy

Shoulder arthroscopy begins with a few small incisions made at the shoulder area. The arthroscope, which is connected with a video monitor, is inserted through one of these incisions. The other incisions are for inserting equipment needed for the repair, reconstruction, etc. The arthroscope helps the surgeon to get a clear view of the shoulder joint and adjoining cartilage, ligaments and tendons in order to diagnose the exact problem.

At the end of the procedure, all the incisions are taped, the area is bandaged you’ll be taken to the recovery room.

Risks and Complications of Shoulder Arthroscopy

Shoulder arthroscopy is a safe procedure and the chances of complications are low. However, it’s important to know the risks and complications so that it’s easier to identify if it actually happens.

Risks include:

• Bleeding, infection, or blood clots.
• Infection, vomiting, nausea, urinary retention, sore throat, headache from the anesthesia. Some serious effects of anesthesia include strokes, heart attacks and pneumonia.
• Shoulder stiffness or weakness and/or loss of some or all sensation.
• The repair doesn’t heal.
• The repair does not relieve symptoms.
• Blood vessel or nerve damage in or near the shoulder.

After Shoulder Arthroscopy

The patient is generally allowed to go home on the same day of the surgery, but with the arm in a sling, which needs to be in place for about one week or a little more depending on the intensity of the surgery. Medications are given to control the post procedure pain. Most of these procedures should be followed by physical or occupational therapy for regaining motion and strength of the shoulder and a speedy recovery. However, recovery can range anywhere from one to six months, again depending on the type of surgery, post surgery care and rehabilitation, and physical therapy.

Care Following Shoulder Arthroscopy

When you are ready to go home, your will be given a list of things to do in order to speed your recovery including the following.

• How long you have to wear the sling will depend on the type of shoulder repair you had. For labral repairs it’s typically worn for 4 weeks. Your surgeon will tell you if it is OK to take it off for physical therapy or grooming.

• Apply ice to the area as per surgeon’s instructions either by using an ice machine or putting ice over the bandaged area. Do not apply ice directly to the skin, put a cloth between your skin and the ice. Do not apply heat to the area.

• In most cases sutures for closing the incision sites are used with reabsorb and does not need to be removed, otherwise, the suture removal is done within seven to ten days after surgery.

• Start eating clear liquids and soups until you see if you are nauseated. Then slowly return to your regularly diet if you’re not nauseated. Sometimes the digestive system is slow to respond after anesthesia or while taking narcotic pain medicine. If you get constipated, use a mild over-the-counter laxative.

• Strong pain pills (narcotics) may be prescribed for the first few days. Pain medicine should be taken exactly as your surgeon prescribes and as needed, but not more often than every 4 hours. Don’t wait to take your pain medicine until you are in a lot of pain; pain medicine works best if you stay ahead of the pain. Do not drink alcohol or take Tylenol while you’re taking pain medicine. You can take anti-inflammatory medicines along with the pain medicine. Take pain medicine with food to prevent an upset stomach. Call your surgeon if you have pain that is not controlled with your pain medicine.

• The bandage around the shoulder area is usually removed in about three days, however, the instructions of the physician should always be followed in this regard. Because so much fluid is used during the procedure, you may notice some bloody drainage on the dressing. If the drainage is excessive, call your surgeon. Do not touch the incisions or put anything on the incision.

• You can take a shower after the bandage is removed in about 3 days. Do not take bath until the wound has healed completely in about 10-12 days.

• Though physical therapy is usually started after one to two weeks after the surgery, some simple exercises are given to the patients to do at home just after the surgery as this helps to keep the shoulder joint mobilized.

• Do not drive until your surgeon say it’s OK; do not drive if you are taking narcotics or muscle relaxants as they can affect your ability to drive.

• If the patient’s job does not involve the affected arm, then returning to work can be within three to five days. However, if it involves the affected arm, it will take a little longer.

When to Call Your Surgeon

What You Can Expect After Shoulder Arthroscopy

Shoulder arthroscopy is a better alternative to open surgery because arthroscopy is less invasive, requires a shorter hospital stay, has fewer complications and a faster recovery. Even so, the affected arm should not be exerted too much, but rather activities should be done only as tolerated.

Complete recovery can take as long as 6 months to a year depending on what type repair was done. Your return to normal depends a lot on your commitment to physical therapy and your overall health.

The spinal column is made up of 26 bones: 24 unique vertebrae plus the sacrum and coccyx (tail bone) located at the end of the backbone. The Vertebrae appear to be chained together). The vertebrae include:
• 7 cervical vertebrae which makes up the neck
• 12 thoracic vertebrae of the chest
• 5 lumbar vertebra or the “lower back”—L1, L2, L3, L4 and L5.

Bones, disks and facet joints of lumbar spine

The back can move in many different directions, it can stiffen as well as be supple. When looked at from the back, the spine appears to be straight, but looked at from the side you can see 2 curves which cause the back to have an “S” shape—it curves forward at the neck (cervical spine) and lower back (lumbar spine) and slightly backwards at the thoracic spine and sacral region. These curves help support the head and provides strength, flexibility and provides super shock absorbing abilities. Many problems with the back are associated with the normal curvature of the back.

Between each vertebra is a cushion called an intervertebral disk. On the anterior side of each vertebra is an oval shaped disk called the vertebral body. On the posterior side of each vertebra is the vertebral foramen, which is an opening through which the spinal cord passes. A crucial job of the back is to protect and support the vital spinal cord and spinal nerves.

Spinal Segment

Segment is made of two vertebrae, the intervertebral disk, and two spinal nerves

A spinal segment forms a functional unit and is made up of two adjacent vertebrae, the intervertebral disk between them, the two spinal nerves that exit from each side of the spinal cord, ligaments and muscles.

Sacrum

Side view of the sacrum and tailbone, the body of the sacrum forms a joint with the 5th lumbar vertebra.

The sacrum is the last segment of the spine. At birth, it is made of several vertebrae. By the time you’re an adult these vertebrae have fused together to form the sacrum. The Sacrum is a large, triangular bone, situated in the lower part of the vertebral column and at the upper and back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones; its upper part or base joins with the 5th lumbar vertebra by intervertebral fibrocartilage and at the bottom it joins with the coccyx or tailbone.

The Lumbar Spine

The Lumbar spine consists of the vertebral body, posterior elements, intervertebral disks, and ligaments. The lumbar spine is made up of the five lumbar vertebrae located between the thoracic spine and the sacrum. This area is commonly called the “lower back”. The lumbar vertebrae are the largest of the vertebrae because of their weight-bearing function supporting the torso and head.

L-5, the 5th lumbar vertebra.

Labeled lumbar vertebra

The function of the structures of the lumbar spine are to protect and support the spinal cord and spinal nerves. The spinal nerves pass through a large hole (foramen) in the center of each vertebrae, which when lined up is called the spinal canal. The lumbar spinal nerves branch off the spinal cord at each level between the vertebrae. The joints—a joint is where two or more bones meet—between the vertebrae contain a disk (intervertebral disk) that acts as a shock absorber.

The vertebrae of the back are “linked” together by pedicles (lamina, transverse process, and spinous process) to form facet joints.

Ligaments of the Back

The function of ligaments is to attach bones to bones and provide strength and stability to the back. Ligaments are strong, tough bands that are not very flexible. The vertebral bodies of the back are connected to each other by multiple ligaments which include:
• posterior longitudinal ligaments
• anterior longitudinal ligaments
• intertransverse ligaments
• interspinous ligaments
• supraspinous ligaments

Tendons of the Back

Tendons are elastic tissues that connect muscles to bones.

Muscles of the Back

Muscles support and move the spine.

Nerves of the Back

Vascular structures of the Back

Arteries supply the vertebrae, ligaments, and muscles with nourishment.

Problems with the Lumbar Spine

• Osteoporosis
• Osteomalacia
• Arthritis
• Ankylosing Spondylitis
• Sacroiliitis
• Lumbosacral sprain and strain
• Acute Cauda Equina Syndrome
• Intervertebral Disk Disease
• Scoliosis
• Spinal Instability
• Herniated Disk
• Spondylolysis
• Spondylolisthesis
• Spinal Stenosis

Additional Information About the Back

• Back Injury
• Lumbar Spinal Fusion Surgery
• Sex After Back Surgery or Back Injury

In the course of a year, people in the United States suffer one billion colds.

So, I caught a cold from that phone, which then turned into a severe cough and I have been worthless for a week—all because I knew better and didn’t do better. So for those of you who catch a cold, these are self-care measures you can take. I managed to shake my cold in 6 days, which is pretty short. I hate being sick, so I didn’t just treat it—I fought it! Here’s what you need to know and do.

Facts About a Cold

• There are over 200 viruses that can give you a cold
• Colds are often spread through shaking hands
• Colds are the most common disease in the world
• In the course of a year, people in the United States suffer 1 billion colds
• You cannot cure a cold, you can only treat the symptoms
• The best thing you can do is prevent the spread of colds and coughs using good hygiene
• Mouthwash will not prevent a cold
• Antibiotics will not cure a cold
• Green or yellow nasal discharge is not a sign that you need antibiotics
• Taking Vitamin C will not prevent a cold, but there is evidence it can help shorten a cold

How Germs Spread

A cold is caused by viruses that infect the lining of the nose, sinuses, throat, and lungs. The virus usually spreads from person to person when an infected person coughs or sneezes germs into the air called “droplet spread.” Germs enter the blood stream when the contaminated air is breathed in. Also, germs can get on your hands by touching surfaces that are contaminated with respiratory droplets that contain the virus, such as wet areas in a restroom or kitchen. Once the germs are on your hands, they get into your body when you touch your face, eyes, nose or mouth. Once you are infected with the virus, you can spread germs to others by touching surfaces that others touch (such as door knobs and telephones) after you cough or sneeze into your hands, or not covering your nose when you sneeze or mouth when you cough.

If you have a cold, try to avoid spreading the infection to others—usually during the early stages of the infection.

Preventing a Cold

There are several things you can do to prevent a cold—they are all easy and inexpensive and worth the effort.

• Stop the Spread of Germs by Washing Your Hands

Clean your hands: Wash your hands often — with soap and warm water — rub your hands together vigorously, scrubbing all surfaces including backs of hands, between fingers, under fingernails and wrists. Wash for 30 seconds. The soap lather combined with the scrubbing helps dislodge and remove germs. The germs stick to the soap and get washed down the drain. Rinse your hands well while keeping them lower than your elbows so the dirty water runs down the drain and not your arms. Always wash your hands after coughing or sneezing into your hands, blowing your nose, after touching someone who is sick, or when using public restrooms or telephones.

Dry your hands well
Use paper towels to dry your hands and to turn off the faucet. If you are in a public restroom, use the paper towel to open the restroom door.

If soap and water aren’t available, use alcohol-based disposable hand wipes or gel sanitizers. You can find them in most supermarkets and drugstores. Be sure to buy sanitizers that contain at least 60% alcohol. When using a gel, rub the gel over all hand surfaces until your hands are dry. The gel doesn’t need water to work; the alcohol in the gel kills germs that cause colds and the flu. If your hands look dirty, use soap & water.

• Cover Your Mouth and Nose When You Sneeze or Cough

Cough or sneeze into a tissue and then throw it away. If you do not have a tissue, cough or sneeze into your elbow or sleeve. Clean your hands every time you cough or sneeze. Make sure all trashcans for tissues have liners; throw the liners out with the trash.

• Avoid Touching Your Eyes, Nose, or Mouth

Germs are often spread when a person touches a contaminated surface and then touches their eyes, nose, or mouth. Germs can live for 2 hours or more on dry surfaces like doorknobs, desks, and tables and even longer on areas that are wet like sinks and faucets.

• Stay Home When You’re Sick; Check With Your Doctor When Needed.

• Practice Other Good Health Habits

- Get plenty of sleep, be physically active, don’t smoke, manage stress, drink plenty of fluids, and eat nutritious food so you can fend off viruses.
- Avoid people that have a cold or cold symptoms.
- Teach kids how to wash their hands and how to sneeze or cough into their elbow or sleeve.
- Humidify your bedroom or the whole house if possible during the winter.
- Routinely clean and disinfect common areas of your home.

Symptoms of a Cold

There is a gradual 1-3 day onset of symptoms. It often starts out as a sore throat, then a fever and coughing. As the cold progresses, the nasal mucus may thicken which is the last stage before the cold dries up. A cold usually lasts for a week or two. But, taking good care of yourself at home can relieve symptoms and help prevent complications if you are otherwise healthy. Unless you develop complications, you shouldn’t need medical treatment. Complications include bacterial infections of the ears, throat, sinuses or lungs which must be treated with antibiotics.

Sometimes a cold will progress to pneumonia or bronchitis. Older adults and people with diabetes, heart disease, or COPD are the most likely to have complications of infection, pneumonia or bronchitis. A high fever suggest you have more than just a cold.

In general you should:
• get plenty of rest so your body can use its energy to fight the cold
• staying at home will keep you from spreading germs
• drink plenty of liquids like herbal tea or hot broth. Avoid foods or drinks with caffeine which can keep you from getting enough sleep
• don’t take cold remedies that combine medicines for different symptoms. It’s best to treat only the symptoms you have and treat them separately so you don’t get side effects from medicines you don’t need. Also, if you have side effects, you won’t know which ingredient caused the problem.

Runny Nose and Sneezing

• if you have post nasal drip, gargle to keep from getting a sore throat
• use disposable tissues instead of handkerchiefs to reduce the spread of germs
• keep the mucous thin rather than thick and sticky. This helps prevent complications, such as ear and sinus infections, and plugging of your nasal passages. To thin the mucous:
- Drink extra fluids. (avoid sugary and high calorie drinks)
- Increase the humidity in the air with a vaporizer or humidifier.
- Use saline nasal sprays or nasal irrigation
• Antihistamines may reduce the amount of mucous. Be careful, because some antihistamines can make you drowsy.

Red, Watering Eyes

• eye drops

Nasal Stuffiness

• Humidify the rooms you are in most or your whole house if possible.
• Use a nasal decongestant. Using nasal sprays for longer than 3 days can lead to “rebound” where your sinus membranes swell up more than before you started the spray. Don’t use over-the-counter nasal sprays more often than 3 days on and 3 days off, unless prescribed by your doctor.

Note: some decongestants are harmful for people with thyroid disease, glaucoma, diabetes, or enlarged prostate. Talk to the pharmacist if you have any of these conditions and buying a decongestant.

Sore Throat

Excess mucous may run down the back of your throat (postnasal drip) and cause a sore throat. If you have post nasal drip, gargle to keep from getting a sore throat. Gargling with warm, salt water can help. Gargling with mouthwash doesn’t help.

Cough

Coughing is how your body gets rid of debris and mucus from the airways during a viral infection. Unless your cough is severe or is keeping you from resting at night, it is better not to treat it. A severe cough can be treated with a cough suppressant, but don’t try to completely stop the cough.

There are two types of coughs. Productive and non-productive or dry cough.

Non-productive, dry cough. A dry, hacking cough may develop near the end of a cold. Dry coughs that follow viral colds are often worse at night and can last up to several weeks. Take over-the-counter cough medicine which contains dextromethorphan for a dry cough. Cough drops can sooth an irritated throat, but most don’t effect the cough.

Productive cough. A productive cough is one that brings up mucus from the back of the throat or the lungs. Productive coughs should not be suppressed to the point they no longer bring up mucus. Use an expectorant cough syrup containing guaifenesin to thin mucus and make it easier for a productive cough to clear mucus. Drink lots of water if you have a productive cough.

Ear aches

The mucous drainage from your sinuses may plug up the eustachian tube between the nose and the ear, causing an ear infection and pain. Don’t blow your nose so hard that you blow the mucus into these tubes.

Head and Body Aches

The mucous drip may also plug the sinus passages, causing sinus infection and pain.
• Take aspirin, acetaminophen, ketoprofen, or ibuprofen. Do Not give aspirin to children!

Fever

If you think you have a fever, take your temperature. Call if your doctor if fever persist despite treatment:
- 102°-103°F for more than 1 full day
- 101°-102°F for more than 2 full days
- 100°-101°F for more than 3 full days

When to Call Your Doctor

What to do if your newborn gets a cold.

The hip joint is one of the largest joints in the body and is a major weight-bearing joint. Weight bearing stresses on the hip during walking can be 5 times a person’s body weight. A healthy hip can support your weight and allow you to move without pain. Changes in the hip from disease or injury will significantly effect your gait and place abnormal stress on joints above and below the hip.

Anatomic Terms

Let’s define some anatomic terms surgeons use as these terms apply to the hip:

• Anterior — the abdominal side of the hip
• Posterior — the back side of the hip
• Medial — the side of the hip closest to the spine
• Lateral — the side of the hip farthest from the spine
• Abduction — move away from the body (raising the leg)
• Adduction — move toward the body (lowering the leg)
• Proximal — located nearest to the point of attachment or reference, or center of the body
• Distal — located farthest from the point of attachment or reference, or center of the body
• Inferior — located beneath, under or below; undersurface

Anatomy of the Hip

Like the shoulder, the hip is a ball-and-socket joint, but is much more stable. The stability in the hip begins with a deep socket—the acetabulum. Additional stability is provided by the strong joint capsule and its surrounding muscles and ligaments. It’s the need for such a high degree of stabilization of the joint that limits movement.

Bony Structures of the Hip

The hip joins the leg to the trunk of the body at the hip joint. The hip joint is made up of the ball of the femoral head that fits into the cup-shaped acetabulum. The depth of the acetabulum is increased by a fibrocartilagenous labrum. The socket of the hip is much deeper than the socket in the shoulder and encompasses a greater area of the ball.

The acetabulum is formed by three pelvic bones—the ileum, ischium and pubis. The shape of the acetabulum is a half of a sphere; the femoral head is about two-thirds of a sphere. Without weight bearing, the ball-and-socket are not completely congruent. As the joint bears more weight, the contact of the surface areas increases as does joint stability. When standing, the body’s center of gravity passes through the center of the acetabula. Obviously, injury to the acetabulum can affect its function of distributing weight bearing.

The hip joint capsule is a dense, fibrous structure which includes the iliofemoral, pubofemoral, and ischiofemoral ligaments. These ligament along with the ligamentum teres and the labrum help with the stability of the hip.

The neck of the femur connects the femoral head with the shaft of the femur. The capsular ligament of the hip joint attaches to the posterior portion of the femoral neck. The neck ends at the greater and lesser trochanter prominences. The greater trochanter serves as the site of attachment for the abductor muscles. The lesser trochanter is the site of the iliopsosas tendon.

The greater trochanter is very prominent and easy to feel on the lateral thigh. It is the widest part of the lower legs and is where the tendons of several muscles attach including the gluteus, obturator, gemelli and piriformis muscles. The lesser trochanter serves as the attachment for the iliopsoas and iliacus muscle tendons.

Muscles of the Hip

It is the muscles of the hip that allow the 4 basic movements of the hip:
• flexion – bend
• extension – straighten
• abduction – take away from the body
• adduction. – bring back toward the body

The hip muscles are divided up into three basic groups based on their location: anterior, posterior, and medial. The muscles of the anterior thigh make up the quadriceps group. The quads make up about 70% of the thigh’s muscle mass. The purpose of the quads is flexion (bending) of the hip and extension (straightening) of the knee.

The gluteal, hamstring and piriformis muscles are located in the buttocks. The gluteus maximum is the predominant hip extensor and helps maintain the normal tone of the iliotibial band. The gluteal and sartorius muscles also help abduct the hip—that is, move the leg away from the midline of the body (using the spine as a midline reference point). It is abduction that allows us to walk sideways.

Adduction—bringing the leg back towards the midline—is performed by the hip adductor muscle group.

The hip also has the ability to rotate internally (medially)—turning the foot inward (pigeon toed) and externally (laterally)—turning the foot out. Medial rotation is needed for squatting. The piriformis muscle assist in lateral rotation of the hip. Lateral rotation is needed for crossing the legs.

The hip muscles do not attach right at the hip joint, thereby giving the hip more stability.

The facia lata, which is not a muscle but the deep fascia of the thigh, is known as the iliotibial band. The function of this band is to prevent dislocation of the hip.

Neurovascular Structures of the Hip

The sciatic nerve is located where it could sustain injury from a posterior dislocation of the femoral head.

The nerves in the hip supply the various muscles in the hip. These nerves include the femoral nerve, lateral femoral cutaneous nerve, and obturator nerve . The obturator nerve is also responsible for sensation over the thigh. The sciatic nerve is the most commonly recognized nerve in the hip and thigh. The sciatic nerve is large—as big around as your thumb—and travels beneath the gluteus maximus down the back of the leg and then branches on down to the foot. Hip dislocation can cause injury to the sciatic nerve.

The blood supply to the hip is primarily from the internal and external iliac, femoral, obturator, and superior and inferior gluteal arteries. The femoral artery is well known because of its use in cardiac cath.

Ligaments

The stability of the hip is increased by the strong ligaments that encircle the hip. These ligaments completely encompass the hip joint. The iliofemoral ligament is the strongest ligament in the body. Damage to the ligamentum teres can result in avascular necrosis because of injury to the artery that supplies most of the blood to the head of the femur. Death of the bone in the femoral head is one cause for hip replacement.

Bursae

Bursae are fluid filled sacs lined with a synovial membrane which produce synovial fluid. The synovial fluid is similar in consistency to raw egg white. Bursae are often found near joints. Their function is to lessen the friction between tendon and bone, ligament and bone, tendons and ligaments and between muscles. There are as many as 20 bursae around the hip. Inflammation or infection of the bursa is called bursitis.

Common Problems of the Hip

• Aseptic or Avascular necrosis
• Congenital Dislocation
• Perthes’ disease
• Aplasia of the acetabulum
• Coxa valga
• Coxa vara
• Osteoarthritis
• Dislocation

Surgery of the Hip

• Hip Replacement
• Sex After Total Joint Replacement

The progression of shoulder rehab exercises is to:
1. relieve pain, swelling and irritation
2. restore range of motion
3. strengthen the joint

A major component of rehab is for you to learn what you can and cannot do—that is, your limitations.

A shoulder injury or surgery (which your body treats as an injury) results in weakness of the structures of the shoulder joint, incoordination of your muscles, and loss of joint function (range of motion). The first exercises you do during recovery must be gentle and safe so that you don’t make the injury worse or reinjure the joint. Progressing through the rehab program properly helps ensure the most effective recovery and increases your chances of returning to full function—in some cases, better function than before your surgery. Because it’s so important that you do the exercises correctly as well as build up your strength gradually, your doctor may recommend that you see a physical therapist to guide you through your rehabilitation. Also, physical therapy is often paid for by insurance programs.

The Purpose of These Exercises

The following exercises can help you in rehabilitation of your shoulder joint after an injury or surgery. These exercises are listed in order from easy to more difficult. You should begin with the exercises to restore range of motion (ROM). This will provide a gentle warm-up as you increase your muscle and joint mobility. Do the exercises slowly and pay attention to any pain you have. As you complete each exercise, do to the next range of motion and then start the strengthening exercises. Do not do any of these exercises without approval from your doctor.

Keep in mind these exercises are meant for rehabilitation and reconditioning following surgery or injury. They are not meant to be used as a regular exercise routine for sports or conditioning. Rehabilitation is meant only to help you gain full flexibility, strength, endurance and balance and to regain normal function of the joint.

Before and After You Do the Exercises

It might be helpful to review shoulder anatomy and function.

Before you start the exercises, warm up your shoulder joint for about 10 minutes with the range of motion exercises. Also, a warm heating pad or warm compresses can help warm up. Warm up helps prevent new injury to the area from doing the exercises.

When you finish the exercises, apply ice to your shoulder for about 20-30 minutes to reduce swelling and speed healing. Don’t place the ice directly on your skin. Before applying the ice, place a towel or cloth on the skin to be iced. To make an ice pack, put ice chips or ice cubes in a plastic bag or wrap them in a thin towel. Place the ice pack over the covered skin at the injury. The pack may sit directly on the injured area.

Muscles and Muscle Groups Affected by the Exercises

Each exercise lists the tissues affected—individual muscles or muscle groups. Some muscle groups have specific names, such as the rotator cuff. Other muscle or muscle groups are defined by their function—bending or straightening.

• Extension straightening a limb or joint.
• Flexion bending a limb at a joint.
• Abduction moving a limb away from the midline of the body (the midline is represented by the spine).
• Adduction moving a limb toward the midline of the body (the midline is represented by the spine).

Range of Motion Exercises for the Shoulder

1. Pendulum Exercise

• Tissues Affected: Shoulder muscles and shoulder capsule.
• Starting Position: Stand and bend forward with the uninvolved arm supporting the upper body on a table or the back of a chair. Holding a 1-pound weight (such as a can of soup) in the involved hand, allow the arm to hang toward the floor.
• Exercise: With the arm hanging freely toward the floor, shift your body weight from one foot to the other, allowing the involved arm to swing gradually like a pendulum.
• Repetitions: Perform the exercise for 1 to 2 minutes as needed and before and after shoulder strengthening exercises.

2. Cane Exercise

• Tissues Affected: Shoulder muscles and shoulder capsule.
• Starting Position: Lie on the floor on your back with your knees bent and both arms straight up toward the ceiling holding a cane, long stick or broom handle.
• Exercise: (1) Keeping your arms straight, slowly lower the cane over your head toward the floor. Return to starting position. (2) Keeping your arms straight, slowly lower the cane to one side and then the other.
• Repetitions: Hold each stretch as tolerated, and repeat 10 to 15 times.

3. Kneeling Reach Stretch

• Tissues Affected: Shoulder muscles and shoulder capsule.
• Starting Position: Begin on the floor on your hands and knees with your hands directly under your shoulders.
• Exercise: Keeping your hands stationary, slowly sit back onto your heels. To increase the stretch, begin with your hands farther from your knees (out in front of your shoulders), and slowly sit back onto your heels.
• Repetitions: Hold each stretch for 15 to 20 seconds, and repeat 5 to 10 times.

4. Internal and External Rotation

• Tissues Affected: Pectoralis muscles and shoulder capsule.
• Starting Position: Standing, holding a towel behind your back with one hand behind your neck and the other hand behind your waist.
• Exercise: Gently move the towel up and down, as if you were drying off your back,
• Repetitions: Repeat 8-10 times, pause, then do the same thing, reversing your hand positions.

5. Corner Stretch (more advanced)

• Tissues Affected: Pectoralis muscles and shoulder capsule.
• Starting Position: Stand close to a corner in a room facing the corner. Hold your arms out straight to the sides, then bend them up at the elbows to make 90-degree angles (your upper arms will be parallel to the floor, your lower arms reaching straight up) and place your upper arms on the wall. Put one foot and knee into the corner.
• Exercise: Keeping your foot and knee in the corner and your arms against the walls, push your chest into the corner. Keep your chin tucked in and breathe deeply. Return to starting position.
• Repetitions: Hold for 30 seconds, and repeat 3-5 times.

Strengthening Exercises for the Shoulder

1. Superman Squeeze (scapular retraction)

• Muscles Used: Shoulder retractors (the trapezius and the rhomboid, which underlies the trapezius), posterior deltoid and external rotator.
• Starting Position: Lie on the floor face down with your arms at your sides or standing with good posture.
• Exercise: Squeeze your shoulder blades together, and reach toward your feet with your hands. Increase the difficulty by lifting your hands off the ground, palms facing downward. If you don’t have neck problems, raise your head off the floor (continue to look at the floor).
• Repetitions: Hold for a count of five, and repeat 10 times, which completes one set. Progress to 3 sets of 10.

2. Wall Push-ups

• Muscles Used: Shoulder protractors (pectoralis muscles and serratus).
• Starting Position: Stand, facing the wall with feet about two feet from the wall.
• Exercise: Place both hands flat on the wall, with your arms straight, shoulder-width apart at shoulder height. Bend your elbows and lower body toward the wall until your chest is a few inches from the wall. Squeeze chest muscles as you push back to starting position. It helps to focus on your chest muscles as you push back.
• Repetitions: Repeat 10 times, which completes one set. Progress to 3 sets of 10.

3. Flexion and Abduction

• Muscles Used: Rotator cuff and deltoid.
• Starting Position: Stand with the arm of the affected shoulder at your side holding little to no weight, letting pain be your guide.
• Exercise: (1) Slowly raise the arm in front of you to 90 degrees, then slowly return. (2) Slowly raise the arm out to your side to 90 degrees, then slowly return. With both movements, keep the shoulder blade from rising up toward your ear. You can perform this exercise with both arms at the same time.
• Repetitions: Repeat 8 to 10 times, which completes one set. Progress to 3 sets of 10.

ROTATOR CUFF EXERCISES

The rotator cuff is a group of four muscles that provide the shoulder with dynamic stability and keep the shoulder girdle (bony arch formed by the collarbones and shoulder blades) depressed. Rotator cuff strengthening is critical to rehabilitation of any shoulder injury and will help prevent reinjury.

STRENGTH

1. SCAPTION (Scaption is the plane of motion that the scapula moves in.)

• Muscles Used: Supraspinatus.
• Starting Position: Stand with no weight or a 1-pound weight in the hand of each arm.
• Exercise: Slowly raise the arms 45 degrees from the front. Keep your shoulder blade depressed, and raise the arm no higher than 90 degrees. Keep your thumbs pointed downward, leading with pinky fingers.
• Repetitions: Repeat 10 times, which completes one set. Begin with one set, progressing to 3 sets, with brief pauses between each set.

2. EXTERNAL ROTATOR

• Muscles Used: Infraspinatus and teres minor.
• Starting Position: Lie on the floor on your unaffected side with a towel between the involved elbow and your body. Your elbow should be bent to 90 degrees.
• Exercise: Holding no weight or a 1- to 2-pound weight, slowly raise your hand toward the ceiling while keeping your elbow at your side on the towel. Slowly return to starting position.
• Repetitions: Repeat 10 times, which completes one set. Begin with one set, progressing to 3 sets, with brief pauses between each set.

3. INTERNAL ROTATION

• Muscles Used: Subscapularis.
• Starting Position: Lie on the floor on your back with the involved elbow bent to 90 degrees. Place a towel between your elbow and body to keep the shoulder in proper position.
• Exercise: Holding no weight or a 1- to 2-pound weight, keep your elbow bent. Slowly lower your hand toward the floor, then bring hand in toward stomach.
• Repetitions: Repeat 10 times, which completes one set. Begin with one set, progressing to 3 sets, with brief pauses between each set.

Anatomic Terms

Let’s define some anatomic terms surgeons use as these terms apply to the shoulder:

• Anterior — the abdominal side of the shoulder
• Posterior — the back side of the shoulder
• Medial — the side of the shoulder closest to the spine
• Lateral — the side of the shoulder farthest from the spine
• Abduction — move away from the body (raising the arm)
• Adduction — move toward the body (lowering the arm)
• Proximal — located nearest to the point of attachment or reference, or center of the body
• Distal — located farthest from the point of attachment or reference, or center of the body
• Inferior — located beneath, under or below; undersurface

Shoulder Anatomy

The Shoulder Joints

A joint is formed where two or more bones meet. There are three joints in the shoulder girdle:
• the glenohumeral joint (GH) is a ball-and-socket joint where the humerus meets the glenoid on the scapula
• the acromioclavicular joint (AC) is a gliding joint where the clavicle meets the acromial process
• the sternoclavicular joint (SC) is formed by the joint space between the sternum (breastbone) and the clavicle (collar bone)

The glenohumeral (GH) articulation forms what people commonly think of as the shoulder joint and is the most important of the shoulder articulations. The GH joint links the humerus (arm) with the thorax (chest). The stability of the GH joint depends on keeping the humeral head centered in the glenoid fossa (socket) on the scapula. The humerus is held in place with ligaments, tendons and muscles, mainly the muscles and tendons of the rotator cuff.

The Glenohumeral Joint (GH)

The glenohumeral joint provides most of the motion in the shoulder girdle. The glenohumeral joint has the greatest mobility of any joint in the body and it seems as if movement would be possible in all directions—but certain structures limit raising the arm straight out behind us to about 60 degrees. This great range of motion can lead to several common problems and injuries affecting the shoulder girdle.

The glenohumeral joint is a ball-and-socket joint like the hip joint. The shoulder is different from the hip in that the hip is a weight bearing joint and the shoulder is a suspension joint. The large, almost perfectly round head of the humerus (ball) fits into the small, shallow glenoid fossa (socket) on the lateral side of the scapula. The shoulder socket is very shallow and comes in very little contact with the round head of the humerus—similar to a golf ball on a tee. Also, the cup of the socket is much lager than the ball that fits into it. At any point in the shoulder’s arc of motion this poor fit and contact of the bones make the glenohumeral joint unstable. Therefore, it is the soft tissues in the joint that maintain stability and mobility.

The soft tissues of the glenohumeral joint include:
• the joint capsule
• the glenohumeral ligaments – function as static stabilizers of the GH joint
• the glenoid labrum – this is a ring of fibrocartilaginous tissue structure that attaches to the rim of the glenoid cavity on the scapula; it increases the depth of the glenoid “socket” by 50%. Its function is to increase the surface contact area for the ball on the humerus. The glenoid labrum also serves as an attachment point for the shoulder capsule, glenohumeral ligaments, and the long head of the biceps tendon.
• the long head of the biceps tendon
• the rotator cuff tendons and muscles

These soft tissues are where most degenerative (wear and tear) and traumatic conditions of the shoulder occur.

The muscles on the lateral side of the shoulder allow movement and stabilize the joint. These muscles are strong on the upper and back sides of the arm, but not on the underside. A strong outside force in this area can cause the head of the humerus to slip out of the glenoid socket, called dislocation.

The Acromioclavicular Joint (AC)

The AC joint helps link the arm to the body at the chest. Since there is little bony stability in this joint, a number of ligaments and other soft tissues stabilize this joint. The superior AC ligament is the most important horizontal stabilizer. The coracoclavicular ligaments help stabilize the clavicle vertically. A significant amount of rotation occurs in the clavicle and about 10% occurs at the AC joint.

The Sternoclavicular Joint (SC)

Most of the rotation occurs at the sternoclavicular joint and joint stability comes from the soft tissues. The posterior sternoclavicular joint capsule is the most important structure for preventing forward and backward displacement of the medial clavicle.

The Rotator Cuff

The rotator cuff consists of four muscle-tendon units that originate on the scapula and attach to the tuberosities of the humerus. The role of the rotator cuff is to keep the head of the humerus centered in the glenoid fossa throughout the shoulder’s range of motion and when raising the arm. The rotator cuff is the primary stabilizer during movement of the GH joint. Both overuse and traumatic injuries to the rotator cuff are the most common problems in the shoulder girdle.

The Subacromial Space

The subacromial space is beneath the acromion and above the rotator cuff. The subacromial bursa outlines this space and provides frictionless gliding of the rotator cuff beneath the arch formed by the acromion and coracoacromion. Bone spurs on the underside of the acromion are thought to narrow this space, irritate the bursa and contribute to tears in the rotator cuff.

Bones of the Shoulder Girdle

Click on image for larger labeled, picture.

The bones of the shoulder girdle include the humerus, the scapula, and the clavicle. There are four articulations (movements) in the shoulder named for their anatomic locations:
• coracoclavicular
• acromioclavicular
• glenohumeral (the only true synovial joint)
• coracoacromial


Scapula (shoulder blade). The scapula is the most complex of the bones in the shoulder. There are three landmarks on the scapula; the spine, acromion and coracoid processes. The roof of the glenohumeral joint is formed by the acromion. The acromion articulates with the clavicle forming the acromioclavicular (AC) joint.

Humerus (upper arm). The humerus is the ball part of the ball-and-socket joint. The head (ball) of the humerus articulates within the glenoid fossa. Below the humeral head is the anatomic neck which separates the head (ball) from the tuberosities. Each tuberosity provides a place for the attachment for the muscles of the rotator cuff—the 4 rotator cuff muscles originate from the scapula and their tendons attach at the humerus. The bicipital groove separates the tuberosities. Just below the tuberosities is the surgical neck of the humerus and is the most common area for fractures of the proximal humerus.

Clavicle (Shoulder Blade) – lateral view

Clavicle (collar bone) . The clavicle originates at the sternum (breastbone) just above the first rib, and is held in place by the acromioclavicular ligament, several muscles and the coracoclavicular ligament.

Ligaments in the Shoulder

Click on image to see larger picture.

There are several important ligaments about the shoulder girdle. Ligaments are soft tissue structures that connect bones to bones. Ligaments are strong, tough bands that are not particularly flexible. Once stretched, they tend to stay stretched and if stretched too far, they snap.

Ligaments, along with muscles and tendons, are the main source of stability for the shoulder. These passive stabilizers serve to keep the joints of the shoulder from dislocating. Some of the main ligaments are the acromioclavicular, coracoclavicular and the coracoacromial.

When injured, the ligament that attaches the clavicle to the acromion—the acromioclavicular ligament—is called a separated shoulder. Two ligaments connect the clavicle to the scapula by attaching to the coracoid process—the coracoclavicular and the coracoacromial ligaments.

Muscles and Tendons in the Shoulder

Each muscle of the shoulder assists with specific movements. The deep muscle group that moves the shoulder are the rotator cuff muscles and tendons. Keeping the head of the humerus inside the glenoid fossa is the primary function of the rotator cuff muscles. This important group of muscles lies just outside the glenohumeral joint and helps to rotate the shoulder in the many directions. This rotator cuff muscles include the:
• supraspinus
• infraspinatus
• teres minor muscles (SIT)
• subscapularis

These muscles are the muscles most often involved in shoulder rehab.

Tendons are elastic, soft, connective tissue structures that attach muscles to bone. The rotator cuff tendons are a group of tendons that connect the deepest layer of muscles to the humerus. As they form their tendinous attachment to the humerus, they become a fibrous capsule. The rotator cuff muscles and tendons control our ability to raise the arm from our side.

The outer muscle layer is formed by the large deltoid muscle which overlies the SIT muscles. This is probably the largest, strongest muscle of the shoulder. The deltoid takes over lifting the arm once the arm is away from the side. Other muscles include the biceps.

Bursa

Subscapularis-bursa

Sandwiched between the rotator cuff muscle layer and the outer layer of large bulky muscles is the large subacromial bursa, also called the subdeltoid bursa. Bursae are everywhere in the body. A bursa is simply a padlike sac found between two moving surfaces that is lined with synovial membrane and contains a small amount of lubricating fluid inside—synovial fluid is similar in consistency to raw egg white—to reduce friction and aid movement. Bursae occur in connective tissue wherever two body parts—other than joints—move against each other. Their function is to lessen the friction between tendon and bone, ligament and bone, tendons and ligaments, and between muscles. Inflammation or infection of the bursa is called bursitis.

Neurovascular Structures

There are several important nerves in the shoulder, but the most important is the brachial plexus which is the nerve supply for all of the muscles that contribute to the function of the arm and shoulder girdle. The most vulnerable to direct injury are the brachial plexus and its nerve branches, the spinal accessory nerve and the long thoracic nerve. Shoulder dislocation is most often responsible for damage to the brachial plexus. Direct trauma to the scapula that causes fracture or dislocation can damage the spinal accessory or thoracic nerves. Injury to spinal nerves can result in the alteration of movement and sensation in the shoulder.

The subclavian artery and vein are the two main vascular structures in the shoulder and are part of the thoracic outlet. Trauma and fractures to the clavicle can injure these vessels. There are many blood vessels that supply the rotator cuff.

Problems of the Shoulder Include:

• Acromioclavicular degeneration
• Acromioclavicular joint separation
• Adhesive capsulitis (Frozen Shoulder)
• Arthritis—rheumatoid, traumatic
• Baseball shoulder
• Calcific Tendonitis
• Cervicobrachial syndrome
• Fractures
• Labral tear
• Growths or Tumors, benign or malignant (Neoplasm)
• Necrosis (cell or tissue death)
• Osteoarthritis
• Rotator cuff injury or disease
• Shoulder instability
• Supraspinatus syndrome
• Sprengel’s deformity

Diagnosis and Treatment of Shoulder Problems

Shoulder Arthroscopy
Shoulder Rehab

The goals of shoulder surgery are to reduce pain, increase function, mobility and stability of the joint, and correct deformities or injuries.