How do you surgically repair a rotator cuff tear? Part 1

This is part 1 of our discussion on rotator cuff repairs.

Previous posts on rotator cuff include:

• What is a rotator cuff tear?

• What causes rotator cuff tears?

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

• How do I treat my rotator cuff tear?

Rotator cuff surgery is a very generic term that encompasses many different procedures.  They can be as minimal as a debridement of the bursa and the rotator cuff with possible removal of any bone spurs called a “smooth and move” procedure.  This procedure is normally reserved for partial rotator cuff tears or rotator cuff tears that are old or have poor tissue quality.  If you have a complete tear of your rotator cuff with good tissue quality and desire a return to an active lifestyle, you may be candidate for a rotator cuff repair. 

A rotator cuff repair is most commonly done by stitching the tendon back to its original site on the humerus.  In active patients who have a old, complete tear with poor tissue quality, the options are more limited, unfortunately.  Luckily, a new procedure called the superior capsular reconstruction may help restore some shoulder function that would otherwise be impossible.

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.

I am now a member of the American Shoulder and Elbow Surgeons! #ASESMembers

I am very happy to announce that I have been selected as a candidate member of the American Shoulder and Elbow Surgeons. The American Shoulder and Elbow Surgeons is a society made up of the leading national and international shoulder and elbow surgeons. As the premier organization of shoulder an elbow surgeons, it strives to serve patients and further research and education concerning shoulder and elbow issues. I couldn’t be happier and honored. Thank you #ASES.

Guest posts coming soon!

I will be introducing guests posts from upper extremity experts that I know and trust, discussing all things involving upper extremity injuries and treatment. As many of my patients also suffer from issues regarding the hand and wrist, I believe that this will be a great resource for patients going forward. Stay tuned!

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 causes rotator cuff problems?

This is a continuation of my blog series on rotator cuff issues. Today, we will discuss what causes rotator cuff problems.

Rotator cuff problems can fall along a wide spectrum of issues.  The most common is inflammation of the rotator cuff called rotator cuff tendinitis.  Along with this issue is inflammation of the bursa sac called bursitis.  Sometimes, the rotator cuff tears off of the humerus bone.  This can range from a small, partial tear of the rotator cuff tendon to a complete tear of the rotator cuff tendon.  Many times, complete rotator cuff tears begin with minor tendinitis that progress to partial tearing and then complete tear.

There are two main causes of rotator cuff tears: acute injury and degeneration.

Injury to your rotator cuff is usually caused by lifting something very heavy with a jerking motion.  This can tear the rotator cuff tendon off of the humerus bone.

Location of rotator cuff pain

Degenerative tears are by far the most common type of rotator cuff tears.  These tears are often caused by wearing down of the tendon slowly over time.  This type of tear usually starts with tendinitis and progress to partial thickness tears and complete tears.  These can be due to repetitive stress or just wear over time.

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

Bicep Tendon issues and repairs

Many people hit the gym to get their beach body where they’d like it to be before the summer, but there are sometimes issues with pain or inflammation that can get in their way.

Biceps tendonitis is the technical term for irritation or inflammation in your upper biceps tendon, which attaches your biceps (the muscle located at the front of your upper arm) to your shoulder bones.  Tendons are tough strips of connective tissue which connect muscles to bones and let you move your arms, legs, and other body parts, and your biceps muscle has three of them: two that attach it to your shoulder bones and one that attaches it to your radius, one of your two forearm bone, at your elbow.

What are some of the causes for a bicep tendon injury?

Biceps tendon damage is most often simply the result of wear and tear due to normal daily use. Tendons age just like everything else in our bodies, and as we age they tend to weaken and degenerate just from being used every day over a lifetime. This slow degeneration can be accelerated by overuse or repeating the same motions over and over.

What are the symptoms of a bicep tendon injury?

If you tear your biceps tendon, the most obvious symptom will be pain—sudden and severe pain. Depending on where the tendon is injured, you may feel this in your upper arm or at the elbow. You may feel or even hear a popping sound when the tendon tears.

Other signs that you might have torn your biceps tend are:

• A sudden, sharp pain at your shoulder or in your elbow as the tendon tears

• Bruising of your upper arm in the injured area

• Weakness in your shoulder or your elbow as the muscle becomes detached

• Difficulty turning your arm and hand between palm-up and -down positions, as the detached muscle is unable to do its work

• The front of your upper arm may appear misshapen if the tendon is torn completely. Muscles, when properly attached, are stretched like rubber bands. When the tendon tears, it no longer holds one end in place and the muscle recoils, forming a bulge in your arm.

What are the treatment options for a bicep tendon injury?

While surgery may be necessary to repair a torn biceps tendon, many people are able to function normally without a surgical repair. The appropriate treatment depends on the type of injury and its severity, and in many cases symptoms can be relieved by the same treatments used for tendonitis. Tears that occur at the elbow require surgical repair more often than those at the shoulder.

Some surgical procedures can be done arthroscopically, using small incisions rather than a single large one, although open surgery has very good results and is the one that I prefer.

Surgical repairs for a biceps tendon injury may include:

Reattaching the remaining tendon to the bone.  This procedure is called a biceps tenodesis.

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.

Use of Platelet-Rich Plasma for the Improvement of Pain and Function in Rotator Cuff Tears: A Systematic Review and Meta-analysis With Bias Assessment. #ASES #AAOS #Health

https://www.ncbi.nlm.nih.gov/pubmed/31743037?dopt=Abstract

I am routinely asked about platelet rich plasma (PRP) treatment for rotator cuff tears. PRP is obtained from a patient’s blood and is then injected into injured tissue like rotator cuffs. Many physicians perform this procedure (I do not), but the effectiveness has not been well established at the time of this blog. The above article looked into the effectiveness for rotator cuff tears. Their conclusion that “significant improvements in PRP-treated patients were noted for multiple functional outcomes, but none reached their respective minimal clinically important differences” shows that the PRP has yet to show any functional improvements for rotator cuff tears. I encourage patients to have frank discussions with their physicians about the potential risks and benefits of this procedure before proceeding.

Shoulder Replacements detailed and their benefits #Health

When people typically think of a joint replacement they will think of a knee or hip.  However, shoulder replacements, though less common, can have a resounding effect on the quality of life of the individual.

Shoulder joint replacement is a safe, effective procedure to help with painful conditions of the shoulder that cannot be adequately managed with medications or therapy.

Why are shoulder replacement procedures performed?

Your shoulder is a ball-and-socket joint that’s comprised of three bones: the upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). The ball, or head, of your upper arm fits into a shallow socket in your shoulder blade.  When your shoulder is functioning properly, a thin, smooth tissue called synovial membrane makes fluid that lubricates the cartilage, allowing your shoulder to move smoothly and easily without much friction. The muscles and tendons that surround the shoulder provide support, and all these structures working together allow the shoulder to rotate through a greater range of motion than any other joint in the body.

Conditions such as arthritis can cause joints to lose their cartilage covering, and when you move, bone will move on bone without adequate protection. The result can be very painful, and you may experience a limited range of motion that hampers your ability to accomplish your daily activities.

What are the different types of shoulder replacement procedures?

Shoulder replacement surgery replaces the ball and sometimes the socket with man-made parts. Often the ball is replaced with metal and the socket is replaced with plastic. The components can be held in place with cement, or they can be made of material that lets new bone grow into the joint component over time, holding it in place.

There are several types of shoulder replacement surgery:

Hemiarthroplasty – the ball part of the head is replaced with an artificial joint that has a stem to extend into the shaft part of the bone. It’s usually used for fractures but is also often used for shoulders affected by arthritis.

Shoulder resurfacing – a different type of hemiarthroplasty that requires the removal of less bone. Instead of removing the ball part of the joint, a metal cap is simply placed over it.

Total arthroplasty – this replaces both the ball and socket and is usually used for specific types of arthritis. Your doctor will take into consideration your age, how badly worn the natural joint is, and the condition of the tendons around the joint. A total arthroplasty will sometimes be performed using a resurfacing component.

Reverse shoulder arthroplasty – artificial components are fitted in reverse, with the socket to the upper arm bone and the ball to the shoulder blade. It’s usually only performed on patients with severe arthritis and extremely poor rotator cuff tendons around the joint. It’s sometimes be used if a patient has both a severe joint fracture and poor tendon function.

I, as your surgeon, will determine the location, type, and extent of your shoulder problem before recommending the type of joint replacement that would be most suitable in your particular case.

Are you a candidate for shoulder replacement surgery?

The decision to have shoulder replacement surgery should be made in cooperation with you, your family, your family doctor, and your orthopedic surgeon

Multiple Treatment Comparisons for Large and Massive Rotator Cuff Tears: A Network Meta-analysis. #ASES #Health

https://www.ncbi.nlm.nih.gov/pubmed/31743220?dopt=Abstract

Here is another large review about the treatment options for massive rotator cuff tears. The investigators looked at studies comparing 8 different treatment methods. They did not find statistically significant difference in the functional outcomes between the groups.

It remains clear that there is no consensus about the optimal treatment option for these large tears. I think this highlights the need for patients to have frank discussions with their surgeons about the risks and potential benefits of each treatment option.

To learn more, visit my page on rotator cuff tears or schedule a consultation.

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.

AC Joint Separation Explained

Since the shoulder joint has the widest range of motion, it also is the most prone to injury from sports incidents, falls, or overuse.

What is an AC joint injury?

The acromioclavicular (AC) joint is formed between the collarbone (clavicle) and the tip of your shoulder blade (scapula). You can feel it by putting your hand on top of your shoulder and locating a bony bump.  You may sometimes hear an AC joint separation referred to as a shoulder separation, but it doesn’t actually involve the shoulder. Instead, it occurs when the collarbone separates from the shoulder blade.  AC joint injuries range in severity from a slight dislocation to a complete separation, and treatments can range from at-home treatments to AC joint surgery.  A slight dislocation is the most common type and causes the AC ligament to be stretched or partially torn. An AC joint may also be partially dislocated, with a completely torn AC ligament.

What are its symptoms?

The symptoms you may experience with an AC joint injury depend on the severity of your injury.

If you have a partial dislocation, you may have the following:

• Tenderness when you touch the joint

• Bruising

• Minor pain when you more your arm

If your AC joint is partially dislocated, you may experience the following:

• Moderate to severe pain

• Swelling

• Pain when you move your arm

• Clavicle moves when it’s pushed

• Painful to the touch

Finally, if you have a completely separated AC joint, you may have the following symptoms:

• Tendency to support your elbow and hold your arm close to your side

• Arm hurts with any type of movement

• Popping sound when you move your joint

• Swelling

• A bump on top of your shoulder, or the outer end of your collarbone may look out of place

• Unstable joint

Sports Nutrition – The Ins and Outs

While many focus on the strength training and exercising as a means for becoming fit, the nutritional piece is equally, if not more, important. 

Here are a few tips on sports nutrition for athletes and people interested in fueling a healthy and active lifestyle:

Fats: Athletes should get 20-35% of their total calories from fats. Apart from being a good source of energy, fats are needed for the absorption of several vitamins essential to body. Good fats can be obtained from almonds, peanut butter, avocados, and olive oil.

Protein: Considered one of the essential building blocks of life, protein is necessary for repair and rebuilding muscle tissue. The daily requirement of protein ranges between 1.2 and 1.8 grams per kg per day. If you wish concentrate on strength training, try to remain within the high end of this range.

Carbohydrates: Your body efficiently converts carbohydrates into energy. Athletes should consume 1 to 4 grams/kg of bodyweight of carbohydrates about 1-4 hours before a game. Endurance athletes may require a higher amount (7 to 10 g/kg/day) of carbohydrates. Try to consume slow-burning carbs such as whole grains or sweet potatoes rather than processed foods.

During activity: If the game or physical activity lasts longer than an hour, you should focus on replenishing electrolytes and glucose. This can be done during short breaks from the game. Sports drinks that contain carbohydrates, electrolytes, and fluids are a good idea for endurance athletes.

Hydration: The importance of staying well hydrated cannot be overstressed. Try to consume 16 ounces of water 2 hours before a game and drink some water every 15-20 minutes while playing to prevent dehydration.

A balanced diet will fuel your endeavors, no matter what they are.  Whether you’re trying to run a 5K or just feeling better from day to day, nutrition

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!

First all-women spacewalk today #NASA

I would like to say congratulations and good luck to NASA astronauts Jessica Meir and Christina Koch as they complete the first all women spacewalk at the International Space Station today. Very cool.

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