Subscapularis repair in reverse shoulder arthroplasty #ASES #Health

https://www.ncbi.nlm.nih.gov/pubmed/31743476?dopt=Abstract

Interesting article about the biomechanics of subscapularis repair during a reverse shoulder arthroplasty. I use a lateralized implant for many reasons, so this article is pertinent to my practice and patients. The article found that a superior repair lead to the least stress on the repair. A failed subscapular repair can lead to shoulder weakness after surgery, so a successful repair is important, although controversial. I will consider this technique in the future and I look forward to more articles on the this subject.

What Questions Should I ask My Surgeon Before Undergoing a Shoulder Operation? #health #Seattle #rotatorcuff

Pain in the shoulders can significantly impact a patient’s quality of life and ability.  Luckily, there are plenty of options, both surgical and non-surgical, that can alleviate this pain.  If a surgical option seems prudent for your situation, you can ask these questions to ensure you are informed prior to the operation:

 What are the alternatives to shoulder surgery?

As with many other shoulder surgeons, it is common to practice a conservative approach to surgery, attempting to seek other options before resorting to surgery.  Understanding these options, like general pain management techniques or therapies, can better inform that patient on the wide array of options for regaining their quality of life.  Even if surgery is necessary, the patient will be informed on other options at the very least.

 What is the risk to not performing surgery?

A common question is whether avoiding surgery will compromise the long-term outcome. This is a case-by-case decision and must be considered carefully by both the patient and physician, but there is a lot of evidence that can be used to help predict this. For instance, with a partial rotator cuff tear the risk of tear progression is low and attempting conservative treatment for several months does not typically affect the long-term outcome. Conversely, an acute rotator cuff tear (one that occurs after a trauma such as a fall) typically responds better to being repaired within a few months rather than waiting several months to a year.

 What is the expected length of recovery?

The recovery from shoulder surgery can be lengthy and again varies from patient to patient depending on a number of factors. Patients should ask and understand how long they will be in a sling, when they can drive, when they can return to work, when they can return to sporting activities, and when they can expect complete pain relief.

 What are the risks of complications?

A patient considering shoulder surgery should have a good understanding of the risks of the surgery. These can vary considerably. An arthroscopic cuff repair, for instance, has an anticipated complication rate of about 1%. Conversely, the complication rate after a shoulder replacement may be 5 to 10%. Additionally, while volume is important as noted above, complications rates can vary between surgeons.

 Getting answers to these questions should help you make the right decision for you. Making sure you’re comfortable with your surgeon and your procedure, as well as understanding recovery expectations are all important for the success of your procedure.

Early Rotator Cuff Shoulder Repairs Lead to Promising Results #Health #rotatorcuff #Seattle

Rotator cuff tears are a very common condition, causing pain and reduced movement of the shoulder. While these injuries may not demonstrate symptoms at first, gradual degeneration may cause shoulder pain and other symptoms to develop within a few years

 "Repairs of isolated supraspinatus tears maintained considerable improvement in clinical and radiographic outcomes at 10 years," according to the report by a French orthopedic surgery research group. The lead author was Philippe Collin, MD, of CHP Saint Gregoire Vivalto Sante. The study provides new evidence that early surgery for supraspinatus tears can improve long-term outcomes by preventing later rotator cuff muscle degeneration.

 The researchers, in a French multi-site clinical setting, identified 511 patients at 15 hospitals who underwent complete rotator cuff tear surgery.  These same patients were had a clinical longitudinal research follow-up ten years later, where 288 patients returned for follow-up evaluation, including MRI scans in 210 patients.

 The results of these patients saw substantial improvement of quality of life as well as general range of motion and use of the affected shoulder. The average Constant score -- a standard assessment accounting for shoulder motion, strength, daily activities, and pain -- improved from about 52 (out of a possible 100) before surgery to 78 at ten years' follow-up. The MRI scans showed similar results with a marked improvement in the quality of the tendon strength.

 Journal Reference

 Philippe Collin, Jean-François Kempf, Daniel Mole[Combining Acute Accent], Nicolas Meyer, Charles Agout, Mo Saffarini, Arnaud Godene [Combining Grave Accent] che. Ten-Year Multicenter Clinical and MRI Evaluation of Isolated Supraspinatus Repairs. The Journal of Bone and Joint Surgery, 2017; 99 (16): 1355 DOI: 10.2106/JBJS.16.01267

Recovery After Shoulder Surgery #ASES #AAOS #Seattle #Health

The group of muscles and tendons that surround, stabilize and allow movement at the shoulder joint are the rotator cuff muscles. Because of this, any surgical procedure on the shoulder will likely have some involvement with your rotator cuff muscles.   No matter the reason for your shoulder surgery, here are some general tips to help maximize your recovery.

 Support your Rotator Cuff

It is important to insure that the muscles that have recently been operated on are supported and allowed to heal with minimal strain.  Wearing a sling or some sort of standing support will allow for this throughout the day and sleeping with a pillow to support the affected side at night will help.   

 Develop your Rotator Cuff

The rotator cuff muscles will take time to heal.  Initially you should avoid putting any strain at all on your shoulder.  After some time however, it’s important to stick to the physical therapists recommended exercises to slowly and gradually re-build the muscles. 

 Manage your Shoulder Pain

Of course pain will be more significant immediately after the operation as compared to a few weeks out.  To manage this, you can rely on prescription or over-the-counter medications as well as inflammation management practices like cold compresses.   In addition, wearing your sling should help reduce shoulder pain and reduce the likelihood of unnecessary strain or damage to the muscles and tendons during the recovery period.

 Gradually get back to normal

Consult with your physical therapist or physician as to when you can begin to resume normal activities with your post-operative shoulder. For example, from about 6 weeks you usually will be able to start using your shoulder for gentle tasks such as washing and dressing while at 12 weeks you will be thinking about using your arm for other moderate activities, such as swimming.

What can I expect when I go in for surgery? #Health #Seattle

Often times people will experience some anxiety when heading into a surgical procedure.  Whether it be because they are going to have to be put under anesthesia,  the thought of waking up with some pain, or the fear of the unknown it’s common to have feelings of apprehension.   Luckily,  knowing what to expect can help alleviate these feelings and lead to a more stress-free pre and post-operative experiences.     The first thing to remember is that everyone who you will come in contact from the moment you enter the facility is highly-trained and there to make your experience positive.    As far as time commitment,  typically you won’t spend a great deal of time waiting before going into the operating room.   During the operation, it can take anywhere from one to two hours to complete the operation however you will not remember this.    Post-operation, you may be required to stay in the hospital for some time in order to monitor your healing and how you come out of the anesthesia and then you will likely have to participate in some sort of post-operative physical therapy that can last from a few sessions to sessions that will span over a series of weeks.   While this may seem like a long process, it is a small price to pay for better quality of life in the long term and the advancements in medical sciences today have allowed for a quicker and more effective healing period than ever before. 

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!

Why does my shoulder hurt? #Health #Seattle

You can experience pain in your shoulder for a variety of reasons, many of which are issues that are minor and shouldn’t worry you.   Your shoulder joint is covered in a tissue that is tough and lubricates the joint articulation (where the bones in your shoulder meet) called cartilage.   When your cartilage is healthy and functioning properly, you are able to experience full range of motion with little to no pain.  However, as we age or when we experience an injury in the shoulder, the cartilage can wear thin or become damaged.  This damage can cause pain and stiffness which will limit your range of motion in the shoulder.    When you begin to experience pain or stiffness in your shoulder, try simple pain relief techniques like stretching, ice, and/or heat.   If pain persists, it may be time to review your options with a shoulder specialist.

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.

Frequently asked questions: Why does my shoulder hurt? #Health #Seattle

Dr,. Andrew Pastor

Q: I have been suffering from worsening shoulder pain and stiffness for several months. I finally had to stop exercising or playing sports because of the pain. The pain is waking me up at night and it's difficult to raise my arm above my head. I don’t recall injuring my shoulder. What could the problem be?

A: This is a question that I am asked on a daily basis. There are many possible causes of your shoulder pain.

The shoulder is a very complex joint that is vulnerable to overuse injuries and arthritis. It is actually the most mobile joint in the body.

The most common causes of shoulder pain are tendinitis/bursitis, arthritis, and rotator cuff tears.

The shoulder is actually comprised of two joints. The acromioclavicular (AC) joint is between the tip of the scapula (shoulder blade) and the clavicle (collarbone). The glenohumeral joint is between the humerus (upper arm bone) and the scapula.

The shoulder joint has a much more shallow socket called the glenoid (on the shoulder blade) than the deep hip socket.. Surrounding the glenoid is an O-ring made of cartilage, called the labrum. The labrum deepens the socket and adds stability. The four rotator cuff muscles and tendons stabilize the shoulder joint in the socket as well as rotate the shoulder. There is a fluid-filled spongy tissue known bursa sac that lubricates and cushions this joint space above the rotator cuff. The biceps muscle attaches to the shoulder in two places and helps control motion at the shoulder and elbow. The strongest muscle in the shoulder is the deltoid which help rotate, flex and lift your arm.

The shoulder joint

Injuries or inflammation of any of these structures can cause shoulder pain, stiffness and diminished range of motion.

In your case, in the absence of an acute injury, overuse of your shoulder (especially repetitive overhead activities at your job or with exercise) and aging may result in inflammation of the rotator cuff (tendinits), bursa (bursitis), and gradual deterioration and eventually tearing of the rotator cuff.

Inflammation in any of these areas almost always cause night pain, especially if you sleep on the affected side. Chronically inflamed shoulders may develop scarring in the shoulder over time that eventually completely immobilize the shoulder joint, which is known as adhesive capsulitis or frozen shoulder.

Osteoarthritis, which is the wearing down of cartilage in the shoulder joint, is another common cause of shoulder pain, especially if you had an old injury that damaged your cartilage. Osteoarthritis may also cause night pain, weakness and limited range of motion.

A torn labrum may cause pain, locking or clicking, or the feeling that your shoulder will dislocate.

There are other diseases that can cause shoulder pain like a herniated cervical disc, but your history doesn’t really support this.

Depending on your history and physical examination, your doctor may want to do X-rays, an MRI, or an ultrasound for more specific diagnostic information.

Treatment options include applying ice or heat, non-narcotic pain medication, TENS (transcutaneous electronic nerve stimulator), physical therapy (including a home exercise program to continue stretching and strengthening and prevent recurrence).

I recommend activity modification by refraining from any aggravating repetitive activities, but you must maintain the range of motion in order to prevent stiffness. Gentle range of motion activities can almost never make your condition worse. .Ask your physical therapist or doctor how much you can use it and don’t immobilize the joint or wear a sling unless specifically told to do so. I hope this helps!

Andrew Pastor

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.
 

Could artificial muscles be an answer for chronic rotator cuff tears?

 Could artificial muscles be an answer for chronic rotator cuff tears?  This is a question that I couldn't help but ask myself while reading this fascinating article.  The rotator cuff is a collection of 4 muscles and tendons that allow us to raise our arms.  As many know, chronic (old) rotator tears are a very difficult problem to treat and can lead to severe disability in patients.

Shoulder specialists have been trying for years to determine the optimum treatment for chronic rotator cuff tears.  Our current treatment for old rotator cuff tears is evolving and may include a simple "clean out" of the joint, placing a graft where the rotator cuff tendon was (a superior capsule reconstruction) or a reverse shoulder replacement.  No one solution achieves return to full function due to the fact that rotator muscles atrophy and are no longer functional.

Artificial muscles may allow us the ability to transplant and replace the atrophied rotator cuff muscles and regain significant function.  Although this research is very exciting, I would be remiss to say that this artificial muscle research is still in it's infancy and has not, to my knowledge, been proposed for use in shoulder surgery, so stay tuned.  

I will continue to research this and other treatments and devices here and on my upcoming website the orthopedicfuturist.com.