Postoperative rehab protocols

As many of you know, physical therapy offices are temporarily closed around the state due to the ongoing coronavirus pandemic. This has left many patients, who recently had surgery, without the therapy that they need. I have made my rehab protocols available on my website here for patients to follow along on a week to week basis. I will continue to see my recent post operative patients in clinic and encourage them to follow-up with me by phone at 425 – 412 – 1875 or send me a message through the Epic MyChart.

COVID-19 Update

I want to give everyone an update of the situation involving COVID-19 in our clinic. We have canceled all non-emergent or non-urgent surgeries until June 1. We’ve also canceled all non-urgent or emergent orthopedic clinic visits at the Everett clinic. Our Edmonds and Smokey Point locations are temporarily closed. We will be seeing patients in our Everett location daily. We are also trying to implement possible virtual video visits. I will keep you updated with any new information. If you have questions or have an urgent or emergent orthopedic issue, please call our clinic at 425-412-1875.

What is shoulder arthritis?

This post is part 1 of my posts on shoulder arthritis.

Arthritis is the abnormal wearing down of cartilage in the joint.  Cartilage is the smooth, protective layer that acts like a cap at the end of bones in joints.  The complete cause of the most common type of arthritis, osteoarthritis, is still unknown.  We believe that it is a combination of genetic and activity related factors.  The other type of arthritis is called inflammatory arthritis and may include rheumatoid arthritis.  

Arthritis in the shoulder is normally between the ball of the humerus and the socket of the shoulder blade.  Patients can also get arthritis between the shoulder blade and the collar bone, called AC joint arthritis.

Stay tuned for my next posts about the diagnosis and treatment of shoulder arthritis.

Shoulder arthritis

How do I treat my rotator cuff tear? #Seattle #AAOS

This post is a continuation of our talk on rotator cuff tears. Today, we will be discussing the symptoms and diagnosis of rotator cuff tears. Previous posts included:

• What is a rotator cuff tear?

• What causes rotator cuff tears?

• How do I know if I have a rotator cuff tear?

Nonsurgical treatment is usually based on avoiding activities that cause shoulder pain, nonsteroidal antiinflammatory medications, and extensive shoulder stretching at home or with physical therapy.  Often times, the pain in your shoulder is secondary to shoulder stiffness.  Once the stiffness has been resolved, the shoulder pain improves significantly.  In the past, many physicians have recommended steroid injections into the shoulder.  Many shoulder specialists, like myself, do not recommend this course of treatment often due to its negative effect on the rotator cuff tendon.  Steroid injections can make the rotator cuff tendon weaker and more prone to more extensive tearing.

If you had a significant injury that resulted in a rotator cuff tear or you have not improved with extensive physical therapy and home exercises, minimally-invasive rotator cuff surgery may be an option for you.  To learn more about rotator cuff surgery, continue reading here.

How do I know if i have a rotator cuff tear?

This post is a continuation of our talk on rotator cuff tears. Today, we will be discussing the symptoms and diagnosis of rotator cuff tears. Previous posts included:

• What is a rotator cuff tear?

• What causes rotator cuff tears?

The most common symptoms of rotator cuff tears are:

• pain at night, especially if lying on the affected shoulder

• pain when lifting or lowering your arm or with specific movements

• weakness when lifting or rotate your arm

• cracking or popping sensation when moving her shoulder in certain positions, especially overhead

Tears that happen suddenly, such as from a fall or when lifting something heavy usually cause intense pain.  You may also notice that you are unable to lift your arm after this injury.
Tears that develop slowly due to overuse, usually begin by some vague pain in her shoulder that progresses to worsening pain and then significant pain and weakness.

Some rotator cuff tears, especially those that occur slowly over time, are sometimes not painful.  These tears, however, may still result in some weakness and other symptoms.

Rotator cuff tears can be diagnosed with history and physical examination on most occasions.  Sometimes, advanced imaging such as MRI or ultrasound can be used to confirm a diagnosis of a rotator cuff tear.

Stay tuned for the next post on rotator cuff treatment.

What is the rotator cuff?

The rotator cuff

A common condition that I see and am asked about in clinic is rotator cuff tears.

Rotator cuff problems are some of the more common and frustrating issues that patients can deal with throughout their lives.  Rotator cuff issues can weaken your shoulder and make activities of daily living, like combing your hair or getting dressed painful and difficult to do.

What is the rotator cuff?

Your shoulder is made up of three bones:

• your upper arm bone, called the humerus,

• your shoulder blade, called the scapula, and

• your collar bone, called the clavicle.  

Your arm is partially kept in your shoulder socket by the rotator cuff.  The rotator cuff is a group of four muscles that come together to form tendons that cover the head of your humerus.  The rotator cuff attaches to the humerus and allows you to lift and rotate your arm.  

On top of your rotator cuff, you have a lubricating sac called the bursa.  The bursa allows your rotator cuff to freely glide when you move your arm.  Sometimes, the rotator cuff or the bursa become inflamed and painful.

shoulder bursa

Stay tuned for more information about rotator cuff tears. More information can be found here.

Questions to ask your physical therapist on your first visit #Seattle

Physical therapists are experts in body rehabilitation and movement. They help improve or restore mobility and reduce painful symptoms through different types of active treatment. Physical therapy may be recommended after undergoing surgery to help you return to activities of daily living.

During your first visit to the physical therapist you may be asked a lot of questions, so a personalized physical therapy rehabilitation plan can be created that will best suit your condition. You too must ask questions to ensure your health goals are achieved through the physical therapy program and so that you fully understand the course of treatment that you will undergo.

Here are some key questions to ask your physical therapist:

Does your physical therapist have any specialized experience in treating your condition?

If you have a musculoskeletal problem, a physical therapist with advanced certification or specialized training in Orthopedics would the ideal choice to design your plan of care. This way you can be sure that the treatment plan will be designed with relevant experience and knowledge.

Will you be seeing the same physical therapist during all your therapy sessions?

Seeing the same provider for all your sessions will help build a rapport and improve communication between you and your physical therapist. You will be better able to give accurate feedback regarding how you feel the therapy is helping you.

If you will be seeing more than one therapist, make sure you ask to meet all of your providers at your initial visit.  Often times, physical therapists will also work with a physical Therapy Assistant to achieve the recommended number of sessions while still being schedule-conscious.

What specific type of physical therapy will be provided for your condition?

Physical therapists employ a number of different types of therapies to regain your motion and lack of pain.  These can consist of manual therapy, ice & heat therapy, ultrasound, electrical stimulation, strength training, aquatic therapy, sports-specific conditioning and functional therapy.  Your physical therapist will design a treatment plan that could include many of these, but they are all to assist with your recovery.

What level of discomfort or pain can be expected during each physical therapy session?

There may be some amount of discomfort or pain during your physical therapy session. However, pain that worsens with each therapy session may be an indication that adjustments must be made to the physical therapy program. Be sure to give your physical therapist precise feedback regarding the intensity, duration, and frequency of your pain.

By closely following the instructions of your physical therapist regarding how to perform your exercises, doing them regularly at home as recommended, and not missing any scheduled sessions; you may be able to keep the number physical therapy sessions to the bare minimum and maximize treatment outcomes.

Cooler Weather is Approaching – Tips to Stay Active all Winter in #Seattle

With cooler weather on the horizon, many people who suffer from joint pain, especially those with existing joint or muscle injuries, are beginning to dread the months to come.  Some may even begin limiting activities outdoors in order to avoid the cold-induced pain.   However, this limiting of physical activity due to colder weather can lead to much worse consequences like weight gain, worsening joint pain, and seasonal affective disorder.

 To stay active during the cooler months, follow these tips!

Wear clothes in layers

Exercise clothing during cooler months should consist of three essential layers. First, wear a thin layer of synthetic material like polypropylene that wicks sweat from the skin. Avoid other fabrics like cotton as it prevents sweat from evaporating. Next, wear a second layer of wool for insulation. Finally, a third layer of waterproof, breathable garment should be employed to keep you dry and warm.

Protect your extremities

When your body senses cooler temperatures, blood flow is directed more to the core of the body to keep your vital organs functioning.  However, this leads to less blood flow to your hands and feet causing for them to get much colder.  Wear woolen head scarves, headbands, hand gloves and socks to protect your ears, head, fingers and feet and keep them insulated. Heat also keeps joint pain under control. When you go for cycling or other winter sports use a helmet to prevent injuries due to falls. Wear goggles or dark glasses to protect your eyes against ice glare and snow.

Choose the right activities

If you don’t prefer to be outdoors in the colder months, there are still plenty of options to stay active.  You can do something as simple as walking around a mall or shopping center or take a class in yoga or group fitness.   This way you can stay active and remain flexible through the winter months.

Swim indoors

You can enroll for indoor swimming classes at your local gym or even just join a gym with lap pools. . Swimming is a great exercise and particularly beneficial for people with arthritis pain. In addition to burning excess calories, swimming engages your joints and increases your range of motion which is helpful if you suffer from joint pain.

Don't let cold weather be your excuse, get moving and fight off those winter blues!

Eat Well for Good Joint Health #Seattle #Health #Fitness

Since bones are living tissues that are constantly working to regenerate and produce new tissue material, the food that we ingest and how remain physically active is vitally important to the maximized production of healthy bone and tissue.

Below are some foods that help boost healthy bone and tissue:

Soy-Based Foods: Foods like tofu and edamame are low in fat and high in protein and fiber. They have anti-inflammatory properties that may relieve joint pain and help with bone and tissue regeneration.

Extra Virgin Olive Oil:  Extra virgin olive oil has been associated with increased levels of bone formation and regeneration. In its pure form, olive oil has a lot of anti-inflammatory and antioxidant properties.

Fish: Fatty fish such as tuna, salmon, herring, and mackerel are rich in omega-3 fatty acids. About 3-4 ounces twice a week will benefit those with rheumatoid arthritis.

Dairy Products: Low-fat milk products such as cheese and yogurt are packed with calcium and vitamin D,  which increases bone strength.

Sweet Potatoes:  a rich source of potassium and magnesium which can aid in boosting bone health.

Grapefruit: This fruit is high in vitamin C, an important vitamin that helps prevent bone loss.

Broccoli: Besides containing a high amount of vitamins C and K, broccoli also contains the compound sulforaphane, which helps slow down the progression of osteoarthritis.

Eating a diet full of these foods will aid in maximizing your bone and tissue regeneration, allowing for you to experience better range of motion and likely better quality of life.

Juggling a Shoulder Procedure and Work

Some people love what they do for their career, some don’t, but the reality is that everyone works to earn a living wage.   In fact, the idea of a joint replacement can often be put off due to not wanting to miss work or worse, be let go due to not being able to perform essential duties.  However, this approach to management of joint-related pain can actually be worse that taking some time off for a procedure.  Generally speaking, your joints are hurting because there is something that isn’t functioning properly and the longer that you wait to have these issues addressed, the worse they can become.   The good news is that having a joint replacement might actually benefit your work output! In a recent study out of England, researchers studied 86 patients suffering from joint-related pain and found that nearly all of the patients working prior to surgery returned to employment following surgery.

More good news on this front is that most shoulder procedures are now fairly routine, meaning that there isn’t much chance that there will be any notable complications as long as you stick with the surgeon-prescribed treatments after the operation!   If you have been suggested surgery as a treatment option and are considering the pros and cons of this route, it is a matter of weighing the long-term vs. short term rewards of doing this.  If you were to stick with pain management techniques like heating pads etc.. you may reduce your pain temporarily but you aren’t reducing the damage being done.  With a surgical procedure, the physician is aiming to repair what isn’t functioning properly, effectively stopping or reversing damage that has been done.   No need to sweat it!

Is this exercise bad for my shoulder? #Fitness #Health #Seattle

The deltoid

Shoulder injuries are very common with sports and exercise.    2 out of 3 people will experience a shoulder injury or problem at some point in their lives.  Deltoid exercises are very common with many who lift weights, however, the anterior deltoid normally gets most of the attention.  The deltoid actually consists of 3 main heads: the anterior, middle, and posterior.  Imbalance in the 3 heads of the deltoid can lead to injuries.  A study conducted by the University of Wisconsin LaCrosse evaluated proper deltoid exercises to see which were most effective.

To determine which exercises are most beneficial for activating shoulder muscles, researchers compiled a list of the 10 exercises most often performed by both recreational lifters and athletes and most commonly prescribed by trainers.

• Barbell upright row

• Battling ropes

• Bent-arm lateral raise, great for the medial deltoids

• Cable diagonal raises

• Dips

• Dumbbell front raise

• Dumbbell shoulder press, tops in training for the anterior deltoids

• Push-ups

• Seated rear lateral raise, excellent for the posterior deltoids

• 45-degree incline row, excellent for the medial and posterior deltoids

Following the testing these exercises on 16 athletes, researchers compiled and evaluated the data.  The conclusions were:

• For targeting the anterior deltoid, the dumbbell shoulder press elicited significantly higher muscle activation than any other exercise tested.

• For the medial deltoid, two exercises came out on top: the 45-degree incline row and the bent-arm lateral raise.

• For the posterior deltoid, researchers found that the seated rear lateral raise and the 45-degree incline row both provided the greatest muscle activation for the back of the shoulder. 

My Take

For the most high yield workout, you are best served starting with weakest rear deltoid with either the 45-degree incline row or the seated rear lateral raise followed by the dumbbell shoulder press to target the front of the shoulders.

Exercise is very important both physically and mentally, but always needs to be done the right way.  I hope that this info will add to your workouts.

Do non-surgical factors affect recovery after a rotator cuff repair? #AAOS #Health #Seattle

A recent paper - A prospective evaluation of predictors of pain after arthroscopic rotator cuff repair: psychosocial factors have a stronger association than structural factors set out to answer this question. 

Many shoulder surgeons like myself have noticed that patients can have a wide range of outcomes after the same rotator cuff repair surgery.  This paper gives further evidence that many psychosocial factors can affect the result of surgery and need to be addressed to maximize a patient's outcome.  Patients with preoperative narcotic use, higher preoperative pain scores, and lower scores on the WORC (rotator cuff questionnaire) index and emotion sections.

I am immensely interested in studying how we can use different technologies and treatments to best address the psychosocial factors that we all have our shoulder and elbow patients.  Check out more about my research in this field here.

If you have a rotator cuff tear and are considering rotator cuff surgery, please ask your shoulder surgeon if there is anything that you can do before surgery to improve your outcome.

Can an “old” treatment find new life for rotator cuff repair treatment? #AAOS #Health #Seattle

A study that was presented at the American Academy of Orthopedic Surgeons has demonstrated that transcutaneous electrical nerve stimulation may reduce the pain scores and opioid use after rotator cuff repairs.  In this study, 37 patients were randomized to use either an active or a sham TENS unit during the first week after a rotator cuff repair.  
Electrical stimulation for pain control was first used in ancient Rome.  The first modern, patient wearable TENS unit was patented in the United States in 1974.  It was initially used for chronic pain patients but its use has expanded to other areas.

TENS unit

Following  arthroscopic rotator cuff repair, the use of a TENS unit during the first postoperative week was associated with significantly lower pain scores and opioid pain medication use when compared to patients who received the sham TENS unit.

I have used the this treatment  as part of my shoulder pain protocol after rotator cuff repair surgery with good results.  I continue to research ways to decrease postoperative pain and improve the overall outcomes of my patients after shoulder surgery.  The study is encouraging and may provide an inexpensive and safe way of improving pain control after surgery.
 

New tech may improve overall health #Seattle #Health #Fitness

A volunteer demonstrates Inspiratory Muscle Strength Training at the University of Colorado Boulder.

Credit: CU Boulder

As many of the know, I focus most my research time on shoulder and elbow conditions, space medicine, and reducing musculoskeletal pain, however, occasionally I will come across an article about general health that I find fascinating.  I read an article today about a 5 minute breathing treatment that was shown in a recent study to lower blood pressure, improve vascular health, boosts fitness and sharpen memory.  The treatment is called Inspiratory Muscle Strength Training.  Here is a link to the article if you would like more information.  This is a technology that I will research more as it may be a good treatment to recommend to my patients, especially those with high blood pressure or interested in increasing there fitness. 

What is elbow bursitis? #Seattle #health

Today, I’ll talk about a common condition that I see in clinic - elbow or olecranon bursitis.  Elbow bursitis, or olecranon bursitis, is inflammation of the fluid filled sac (bursa) at the tip of the elbow due to trauma, infection, or inflammation.   Some have referred to this condition as “Popeye elbow” because of the swelling and the bump that develops at the tip of the elbow.  The normal olecranon bursa provides protection and decreases friction to the elbow joint and contains only a small amount of fluid. 

Bursitis of the elbow can occur for a variety of reasons including:

• Trauma to the tip of the elbow causing swelling and fluid build up

• Repetitive stress to the elbow.

• Infection

• Gout

• Rheumatoid arthritis 

Treatment of the bursitis depends on the cause.

In general, most cases of elbow bursitis can be treated with time, prevention of repetitive stress to the elbow, and compressive ACE wraps.  There are certain conditions, however, that have specific treatment as seen below.

Infection

Bursa aspiration

Most infections can be treated with either oral or IV antibiotics.  Your doctor may also recommend aspirating (see Figure), or removing the fluid with a needle.  This can provide useful information, including the type of bacteria, but can also provide some pain relief.  Very rarely, I have to perform an arthroscopy to clean out the infected bursa.

Trauma

Most bursitis related to trauma resolves on its own once the injury has been treated.

Repetitive stress

This is the most common cause of bursitis that I see.  The key to preventing olecranon bursitis due to repetitive stress is to stop the repetitive trauma.  This can be as simple as not resting your elbow on hard surfaces, but may include placing pads on your table or desk, or in extreme cases - wearing an elbow pad for a period of time.

Gout and rheumatoid arthritis

Treatment of the underlying disease, normally improves the symptoms of the bursitis.  On occasion, the bursa will become chronically scarred or will have abnormal material due to gout that may have to be surgically removed.

Conclusion

Elbow bursitis is very common and is generally easy to treat.  It can be frustrating, however, due to the high rate of recurrence.  Please reach out to me or your primary care provider if you think that you have elbow bursitis and would like treatment. 

Thank you,

Andrew Pastor