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Sunday, November 6

Biceps tendon repair in the elbow

A tear of the distal biceps usually occurs in a man in his 50's or 60's.  The patient might feel a pop or tear.  Usually the injury occurs while lifting or lowering a heavy object.  A "popeye" deformity of the biceps muscle can sometimes be obvious, where the muscle "balls up" in the arm.  If a biceps tear has occurred, surgery is one option to regain strength and restore the normal contour of the biceps muscle.  Repair of the tendon should be considered in active patients.  The technique demonstrated here has the advantage of early motion, which begins the day after surgery.  Early motion allows for early healing and a faster, more complete recovery.

Thursday, April 21

An alternative to shoulder replacement? A new technique shows promise: Superior Capsular Reconstruction

The rotator cuff is a series of four tendons that stabilize and move the shoulder.  Rotator cuff tears are a common problem and can sometimes be treated without surgery.  Surgical repair of the torn tendon or tendons is sometimes required.

Superior capsule reconstruction 0 large
Superior capsular reconstruction (source: Arthrex)
Occasionally, a tear is so severe that a repair cannot be performed.  Sometimes this is the result of a failed attempt to repair the tendon, and sometimes it is just the process of aging that makes it impossible to repair.  These tears are called "irreparable".  In a patient with this problem, options are very limited.  In general, the patient must either live with the problem or have the shoulder replaced with a special replacement called a "reverse" shoulder replacement.  The reverse shoulder replacement takes the place of the torn rotator cuff, but it is a big surgery and sometimes does not work.

Superior capsular reconstruction was developed in Japan as an alternative to shoulder replacement for patients with massive irreparable rotator cuff tears.  The technique involves taking a tendon or skin graft and reconstructing the top of the shoulder.  This technique reproduces the normal function of the rotator cuff.  Early results have been promising.  One study showed a significant increase in motion and strength in 23 patients treated with the technique.  Pain was also significantly improved. 

Who might benefit from this new procedure?  Ideally, a younger patient (50's or 60's) who has an irreparable rotator cuff tear but doesn't want a shoulder replacement. 

In my practice, I have begun to offer this procedure to selected patients.  Early results have been good, but the technique is still new and the results very early.  Time will tell if this procedure works well for everyone.  The good news, though, is that it is minimally invasive, safe, and still allows for a shoulder replacement to be placed later.

Wednesday, November 4

Pectoralis Major Tendon Rupture in a Football Player

Pectoralis major (pec tendon) tears occur in young, active, male patients.  A torn tendon is usually obvious, and surgery is usually necessary to repair the torn tendon to restore strength and function.  Here I repair a torn pec major tendon in a college football player.

Monday, October 12

Did I tear my pec tendon?

In a previous post, I described a pec major tendon tear.  The pectoralis major is the large muscle on the front of the chest.  The tendon attaching the muscle to the test can tear, and this almost always happens in an athletic male performing bench press.  A torn pec tendon is very obvious:  the weight drops, there is severe pain and a feeling of something tearing, and a bruise usually develops.  The pec muscle looks deformed or "caved in".
A right pec tendon tear.

A pec tendon tear is more common in someone who uses steroids, because the muscle grows so big that the tendon can no longer handle it's force.  The presence and severity of a pec tendon tear is confirmed on MRI.
MRI: Arrows show the separated tendon.
A pec tendon tear can be partial and may not need surgery.  If the tear is more serious, however, then surgery is necessary to repair the tendon in order to maintain strength and a normal appearance.  Here I demonstrate the latest technique for repair of the pec major tendon.  A strong initial repair allows for early return to gym activities.


Surgery is very successful and 90% of patients are able to get back in the gym and back to their pre-injury level of function.

Tuesday, August 25

Distal Biceps Repair with Achilles Allograft

A distal biceps tear usually happens to a man in their 50's or 60's.  The biceps tendon usually tears with a heavy lift, or when lowering something to the ground.  Some people describe the sensation as being hit in the arm, a "pop", or like being shot in the arm.  Often there is immediate deformity, but not always.

Most people choose to have surgery to repair their biceps, but if several months have passed, the tendon can become scarred and impossible to repair.  In these cases, a graft can be used.  A graft is a tendon from a cadaver that has been specially prepared.  Here I repair a tendon that was torn 12 weeks ago.  The tendon was shortened and retracted and scarred, and could not be repaired.  I used a graft to reconstruct the torn tendon.
The tendon is seen.  It is too short and scarred to repair.

Here a graft has been sewn to the stump of the tendon.  The graft provides the length needed to repair the tendon back to the bone.

A hole has been drilled in the bone to accept the tendon graft.

The new tendon can easily be brought to the hole without any tension.  This ensures the tendon graft will not tear when used.

Here the tendon repair has been completed.  The graft is "docked" into the hole in the bone.

Saturday, June 20

Rotator Cuff Presentation to Missouri Administrative Law Judges

I was honored to speak to the Administrative Law Judges at the Missouri Division of Workers' Compensation 2015 Annual Meeting.  Often, I am asked to give my expert opinion on causation in rotator cuff tears.  Rotator cuff tears can occur from an injury, but also occur from "wearing out" over time.   I had a very interesting discussion with the judges about their legal perspective on this question.

Sunday, February 1

Do I have carpal tunnel syndrome?

Carpal tunnel syndrome is caused by a pinched nerve in the wrist.  Since the nerve is being compressed, signals can't flow through the nerve.  This causes pain, tingling, and numbness in the hand.  The pinched nerve is sort of like stepping on a garden hose.  When you step on the hose, water can't flow out the end.  With a nerve, when normal signals can't get through, your body perceives that as tingling and numbness.

One of the most reliable ways to know if you have carpal tunnel is to ask:  "Do I wake up at night with my hands numb?"  Most people with carpal tunnel syndrome will wake up at night with numb fingers, and have to "shake it out" by shaking their hands.  Most people with carpal tunnel will also notice their fingers going numb when they drive or hold a phone.

If left untreated, carpal tunnel syndrome can cause permanent damage to the nerve in the wrist.  People with moderate or severe carpal tunnel syndrome might consider carpal tunnel release surgery.  Carpal tunnel release is an outpatient procedure designed to relieve pressure on the pinched nerve.


Carpal tunnel release is a common procedure.  In this video I perform a carpal tunnel release.  The skin is open and the surgical scalpel is used to release the ligament compressing the nerve underneath.

Thursday, November 20

Should I have surgery for frozen shoulder?

Frozen shoulder is a problem that will eventually get better on its own.  The bad news:  that can take more than a year.  If injections and medications don't help, some patients choose surgery.  In my practice, about 25% of patients with a true frozen shoulder choose surgery after trying everything else.  Surgery for frozen shoulder is very successful, but depends on careful physical therapy post-operatively.  It's important to remember that there is no time where surgery is absolutely necessary for frozen shoulder; it's just an option if pain and stiffness are so bad that a patient can't wait for it to get better.  Here is a video of the surgical procedure, where thickened ligaments are released to regain motion.  Surgery is done arthroscopically, through small incisions, and patients go home the same day.  Therapy is starting on the day after surgery, to prevent the shoulder from "re-freezing." 

For more general information on frozen shoulder from a previous blog post, including injections for frozen shoulder, click here:  http://blog.doctorfrisella.com/2012/11/more-about-frozen-shoulder.html

Monday, October 6

New Rotator Cuff Repair Video

Just finished a new rotator cuff repair video.  A rotator cuff repair is the most frequent surgery that I perform.  Most patients with rotator cuff tears are in their 50's or 60's.  Tears can occur from wear over time, or be the result of an injury or accident where the tendon is torn away from the bone.  Thanks to John Dattilo for the video editing!

Thursday, July 17

Arthrex Teaching Event with Dr. Burkhead

Had the opportunity to lecture and teach arthroscopy at the Arthrex-Apollo Surgical Master Shoulders Course, along with Dr. Matt Smith M.D. from the University of Missouri and Dr. Buzz Burkhead M.D. from Dallas, Texas.  These guys are truly experts in shoulder surgery and I was honored to be included.

Thursday, April 24

Why does my shoulder hurt at night?

Shoulder Inflammation
Many patients will tell me that their shoulder doesn't bother them much during the day, but at night, if they roll over on it, it hurts.  Sometimes shoulder pain keeps people from getting to sleeping at night, or wakes them up during the night.  This can be very frustrating.

Many different shoulder problems can cause pain at night, but the most common are tendonitis and bursitis.  These conditions cause inflammation, and inflammation bothers is the worst when the shoulder is resting, not moving.  You can think of inflammation like sunburn: red, hot, and painful, and worst at night.

For many people, taking two Tylenol, two Alleve, and a Benadryl about 30 minutes before bedtime can help significantly with nighttime pain.  the Tylenol acts to control pain, Alleve is an anti-inflammatory, and the Benadryl provides sedation to help stay asleep.  Of course, do not try this without first asking your physician if it's OK for you, but I have found this very helpful in getting patients to sleep through the night. 

If nighttime shoulder pain continues beyond a few weeks, it's probably worth seeing a doctor to see if it's something more serious (like arthritis, a frozen shoulder, or a rotator cuff tear).  Cortisone injections can be very helpful for nighttime pain.

Monday, February 17

Bench press injury: It's a pec tendon tear!

The pectoralis major is the large muscle on the front of the chest wall, and attaches the arm to the rib cage.  The pec major tendon can tear (or rupture), just like any other tendon in the body.  However, the pec tendon almost always tears in young, muscular men, usually while doing the bench press.  Using steroids can increase the risk of this muscle tear, because steroids allow the muscle to grow so large that the tendon can no longer handle the force that the muscle generates.  A pec major tendon rupture often feels like being hit with a bat, and usually causes an obvious bruise and deformity.

Someone with a pec tendon rupture needs surgery to repair the tendon for full function, especially the typical patient who is young, healthy, and active.  The repair is done through a small incision near the armpit, and stitches (sutures) are used to pull the tendon back into its normal position.


Pec tendon tear: Note bruising and dimple on the right side of the chest.

Thursday, December 12

What's a Reverse Total Shoulder?

In the past 15 years, there has been a remarkable advance in the world of shoulder surgery in the form of a new type of shoulder replacement called a "reverse" total shoulder.  In surgery, it is rare that something truly new comes along.  The reverse shoulder replacement represents a real improvement in a surgeon's ability to treat severe shoulder problems.

A Diagram of a Reverse Shoulder Replacement
What's new about it?  Unlike a standard shoulder replacement, the ball and socket are completely reversed.  In a normal shoulder replacement I remove the ball and socket and replace them with a new metal ball and plastic socket.  In a reverse total shoulder,  the metal ball actually goes on the socket side of the shoulder and the plastic socket is placed on what used to be the ball side.  Because the ball and socket are now opposite from their normal position, they are "reversed"--thus the term "reverse shoulder replacement."

Why is it needed?  What's so great about it?   Before the reverse total shoulder, there was no good way to treat the combination of shoulder arthritis and severe rotator cuff tendon tear.  We could treat shoulder arthritis with a regular shoulder replacement.  We could treat a tendon tear with a tendon repair.  But the patient with both of these problems at once could not be effectively treated.  There was literally no good answer for someone with that combination of problems.  The reverse total shoulder replacement was developed to provide a solution to that problem, and so far it has proved enormously successful.

Reverse shoulder replacement is only appropriate for a small number of patients with a very specific set of problems.  In my shoulder practice, I perform about 30-40 reverse shoulder replacements a year. Like any surgery, there is a risk of complications, and any decision to proceed with a replacement should only be undertaken after a careful evaluation and discussion with your surgeon.

To read more about reverse shoulder replacement, the American Academy of Orthopedic Surgery has a nice summary for patients at http://orthoinfo.aaos.org/topic.cfm?topic=A00504

Thursday, December 5

New Shoulder Study: An Alternative to Cortisone Injection

A May, a new study was published in the Journal of Shoulder and Elbow Surgery which suggests an alternative to cortisone injection for people with shoulder pain.  For years, cortisone injections were given to patients with longstanding shoulder pain, because it works effectively to decrease inflammation.  This new study looked at a different medication, called toradol, to decrease inflammation in shoulder pain.  The researchers compared an injection of toradol with an injection of cortisone for people with pain in their shoulder. 

The result:  both medications worked to decrease pain and improve function.  However, the patients who received the toradol injection had better improvement in function and pain at the four-week mark compared with those who received cortisone. 

This information is quite useful, showing that there is an alternative to cortisone for patients with shoulder pain.  In my practice, I usually use toradol injections for patients who have not had benefit from cortisone.  This study may change my practice, and I may be more likely to recommend toradol instead of cortisone.  However, it is possible that the type of cortisone injection matters:  I use a long-acting cortisone medication, while this study did not.  Also, cortisone injections may give quicker pain relief, important for someone with significant pain.

Overall, though, this study is good news for those with shoulder pain, expanding the options for treatment.  To read more, here's the link to the study:

http://www.jshoulderelbow.org/article/S1058-2746(12)00372-2/abstract

For more on cortisone injections, here's a previous blog post:

http://blog.doctorfrisella.com/2013/01/are-cortisone-injections-bad-for-you.html

Thursday, October 3

Does Physical Therapy Work?

I sometimes have patients who are very reluctant to consider physical therapy.  Sometimes they have had a bad experience with therapy--it hurt more or didn't help.  Certain patients felt that the therapist was not spending enough time with them, or that their therapy was too expensive.  Others say that they feel like they could easily do the therapy on their own at home.

Physical therapy has significant value, and can definitely cure certain shoulder conditions.  Therapy is useful for patients with rotator cuff tendonitis, bursitis, and shoulder blade pain.  It is also very helpful for patients with neck pain. Physical therapy is absolutely necessary in order to achieve maximum benefit after shoulder surgery.  Many patients can become pain-free if they 1) take it seriously 2) show up to their therapy sessions and 3) do their home exercises.  About 50% of the patients that I send to therapy come back and tell me that it completely relieved their pain.

It is important to understand that certain conditions do not improve with therapy.  Carpal tunnel syndrome, for instance, is a problem that causes wrist and hand pain and tingling and numbness in the fingers.  Patients with carpal  have a nerve is compressed in the wrist.  No amount of exercise, stretching, or strengthening is going to relieve the pressure on the nerve, and physical therapy is not prescribed.  Another example is shoulder osteoarthritis.  Although therapy may be helpful to improve motion and strength in the shoulder, it is unlikely to significantly improve pain in the shoulder with arthritis.  It is unrealistic to think that therapy will cure arthritis.

Physical therapy is a great place to start for many shoulder conditions, but especially for those involving the rotator cuff.  Physical therapy definitely works, but as with any treatment, there are no guarantees and some patients do not respond.  If you have had shoulder surgery, therapy is absolutely necessary for a full recovery.  If therapy is not helpful, many patients benefit from steroid injections.  See my other blog posts about that!

Finally, here is a video that demonstrates the two basic rotator cuff strengthening exercises.  Doing exercises on your own is never as helpful as actually going to a therapist, but if your problem isn't too serious, it's not a bad place to start.  Ask your doctor before starting any therapy program!

Monday, July 22

Rotator Cuff Tears Don't Always Hurt


Rotator cuff tears are tears in the tendons of the shoulder.  Most people know about rotator cuff tears, but are surprised to learn that having a rotator cuff tear is not always painful.  Most tears happen slowly over time.  These tears are called "degenerative" tears because they occur slowly and are not the result of a single injury.  On top of that, they are often not painful.  Most people don't even know they have a tear until it starts to bother them.  They may notice a loss of strength but no pain, and many do not seek treatment because the process is so slow.  Recently, researchers in Norway did a study that asked the question:  "If a person has a rotator cuff tear that doesn't hurt, what happens to it over time?"  This question is important to answer in order determine the right course of action for people with a torn rotator cuff.  If tears don't get any worse with time, then maybe surgery can be avoided.

In this Norwegian study, researchers did MRI scans on people with no shoulder pain.  They found 80 people with a rotator cuff tear that was not painful.  These people did not even know they had a tear, it was only found because they were in a study.  The researchers then followed along, without doing surgery, for three years.  During that time, about 40% of the people began to feel pain, and many of them had tears that increased in size and severity.  In other words, many people got worse and their tears got worse.  This information is important, because it suggests that when a tear is found, it ought to be fixed to give a person the best chance of healing and to prevent the tear from getting larger.

There are limitations to studies like this, but it suggests to me that younger patients (less than 65 years old ) with rotator cuff tears should strongly consider surgery, because the tear has a good chance of worsening with time.  Doing nothing is not going to get the tear to heal.  This is why I most often recommend rotator cuff repair for my active patients younger than 65 years old. 

Here is a video of a rotator cuff repair:

Thursday, May 30

Arthrex Teaching Event

Last week  had the opportunity to demonstrate surgical procedures in a cadaver lab.  Thanks to Apollo Surgical and Excel Physical Therapy for sponsoring the event.  I was able to demonstrate what actually happens in surgery when I do a shoulder arthroscopy or "scope".  The audience included physical therapists, nurse case managers, and insurance adjustors.  It is always helpful for therapists, nurses, and case managers to better understand what actually happens in surgery, to keep everyone on the same page in the post-operative period.
Shoulder surgery in a cadaver... that's me pointing

Monday, April 29

Fall and bump on shoulder = it's a shoulder separation!

My friend called me last night and said "I think I dislocated my shoulder!"  When he told me that he had a large bump on his shoulder, I knew that it was probably not a dislocation but a shoulder separation, where the joint between the shoulder blade and collarbone is disrupted.  This causes a large bump where the collarbone sticks up.  Here's a picture of his shoulder.
Picture of a bad shoulder separation
Shoulder separations usually occur from falling directly onto the shoulder.  Shoulder separations are also called AC separations.  "AC" stands for acromioclavicular, which is the joint between the collarbone and shoulder blade.  Some shoulder separations are minor, and do not require surgery.  Others are more significant, and need surgery to reconstruct the ligaments holding the collarbone.  Here's a picture of the x-ray.  Can you see the end of the collarbone sticking up?
Shoulder separation
If there is only a small bump and the collarbone is not too far from its normal position, the ligaments in a shoulder separation will heal just fine on their own without surgery.  It is important to understand that the bump will be permanent, but there will be no loss of strength.  In the case where there is a large bump and the collarbone is way out place (as with my friend here), then surgery is necessary to repair the torn ligaments.  Here is a video showing repair of a shoulder separation or AC separation.
 

 

If you think you might have a shoulder separation, getting an x-ray will confirm the position of the bones.  A shoulder surgeon should be able to help you understand your options and whether or not you need surgery.

Wednesday, April 3

I tore my biceps tendon! Now what?

The biceps muscle
Everyone knows the biceps muscle, the large muscle on the front of the arm.  The biceps has a tendon at the top of the arm that attaches in the shoulder and and another tendon that attaches at the elbow.  The biceps can be torn in either location.  Either type of tear can cause a "popeye" deformity in the arm, and means a loss of strength. 

Most people who tear their biceps tendon are male, in their 50's or 60's, and are lifting something or lowering something down.  Most say something like "it felt like I got hit in the arm" or "it felt like somebody shot me in the arm."  They will have pain and notice an extra bulge in the arm.  The bulge occurs because one end of the tendon has broken free and pulled back, like a rubber band, and the muscle balls up, creating a bulge.
Here's a picture of a torn biceps tendon.  Can you see the bump in the arm?
A torn biceps tendon causes a bump in the arm, or "popeye" deformity
Here's a video of a biceps tear as it happens:


Some people don't want surgery to repair their torn biceps.  For active people in their 50's and 60's, however, many patients choose to have surgery to repair the torn tendon.  Repair will restore the normal look of the muscle, increase strength, and prevent cramping that comes from having a torn, balled-up muscle.  Surgery is an outpatient procedure that is done through a 1-2 inch incision in the arm.  Recovery from surgery takes three months until return to full function.  

If you think you've torn your biceps, you should see a specialist to discuss your options.

Thursday, January 17

Are Cortisone Injections Bad for You?

I give many cortisone injections in my practice because cortisone is a powerful, effective anti-inflammatory.  Most shoulder problems are the result of inflammation, and cortisone is the most effective medication to treat inflammation.  Period.  Why do I use cortisone injections?  Because they work really, really well.  Like any medication, though, cortisone has benefits and risks.  Here I will try to answer common questions about cortisone injections.

First, what is cortisone?  Actually, cortisone is just one of many medications in a group called corticosteroids.  Other corticosteroids include prednisone, prednisolone, methyprednisolone (medrol), and dexamethasone.  Most people just say cortisone to mean any of these medications.  Cortisone and the other corticosteroid medications work by decreasing the body's immune response--it is an anti-inflammatory. Inflammation is the immune system flaring out of control and causing pain.

Is cortisone just a "temporary fix"?  For many people, a single cortisone shot is an effective, permanent solution to an inflammation problem.  If inflammation is like a fire, then cortisone is the water to put the fire out.  Sometimes the fire, or inflammation, is completely eliminated by the cortisone.  Sometimes, though, inflammation remains, and can flare back up.  For some people, the cortisone shot doesn't put out the fire completely and they have pain and inflammation come back.  And for some people, the injection doesn't work at all.

Doesn't cortisone damage the tendons and ligaments in my shoulder?  There may be a very small effect on the tendons in the shoulder.  However, a single injection is absolutely safe and causes no weakening.  With multiple injections, however, there is a risk of weakening tendons in the joint.  If multiple injections might be necessary, then you should know about this small but real risk.

Are there any other side effects of cortisone?  In patients with diabetes, cortisone may cause a temporary increase in blood sugars.  This effect wears off after a week or so.  There is a small increased risk of infection after a cortisone shot, because the shot decreases the body's ability to fight infection. 

How is the injection given?  In my practice, I use a small ultrasound machine to guide the injection into the correct location.  Here is a video of a cortisone injection:

Thursday, November 1

More About Frozen Shoulder

Frozen shoulder happens when inflammation develops inside the shoulder joint.  Frozen shoulder is also called “adhesive capsulitis”.  The inflammation from frozen shoulder causes pain at first, but over time causes thickening of the ligaments inside the shoulder.  This thickening of the ligaments is similar to the formation of a scar.  As this occurs, the shoulder becomes progressively more stiff.  This process occurs slowly over many months.  Most people start to notice that they can’t put their hand behind their back, to put on a bra or put a wallet in the back pocket.  Pain at night is very common, and throwing or reaching above the head become difficult or impossible.  We don’t know why frozen shoulder happens, but it is more common in patients with diabetes or thyroid problems.  Sometimes it starts as the result of a minor injury.  Most often, though, it begins for no reason at all. 

It is not always possible to tell the difference between pain from frozen shoulder or pain from arthritis, bursitis, or tendonitis.  Only your physician can make a definitive diagnosis.

The good news is that frozen shoulder is not a permanent problem.  It will always get better on its own, but slowly, over many months.  It can take up to one or two years for the pain to completely go away and the shoulder motion to return to normal.  Most people don’t want to wait a year for the symptoms to clear up.  So what can be done?


In my practice, I usually start with cortisone shots.  Since the problem is related to inflammation, and cortisone is a powerful anti-inflammatory, cortisone shots help most people get past the worst of the pain and stiffness.  These injections are done with the help of an ultrasound machine, which guides the injection into the correct spot.  Most people will have significant relief of pain with cortisone injections.  Some people, though, may continue to experience stiffness even if the pain improves.

Patients with persistent stiffness sometimes benefit from a simple surgical procedure called a “manipulation and release”.  This procedure is done under general anesthesia.  First, the shoulder is gently stretched to break up the scar tisuue.  Then, through small “arthroscopic” incisions about one-half inch long, the inside of the shoulder is cleaned up and the tight scar tissue is removed.  Most patients recover fully from this surgery within 6 weeks, although it may take longer.  The results are generally very good.


To summarize, frozen shoulder is a problem of inflammation in the shoulder.  It results in pain and stiffness, and is treated with cortisone injections.  If cortisone shots don’t work, then a simple arthroscopic surgical procedure may help. 

Monday, October 15

Release for Frozen Shoulder

Here I perform a release for a frozen shoulder.  Frozen shoulder is a condition that can be a result of injury, but often happens for no reason at all.  It can occur in anyone, but is more common in people with diabetes and thyroid problems.  A closed manipulation (seen here) is performed to break up the tight, inflamed tissue that causes the shoulder to be "frozen".  By breaking up this tight scar tissue, the shoulder mobility is greatly improved.

Thursday, October 11

Do I Need Surgery for my Torn Rotator Cuff?

Let's start with this: you have shoulder pain, and have seen a doctor about it. The doctor orders an MRI, and it shows a tear in the rotator cuff. You might then ask: will the tear heal on its own? do I need surgery?

First things first: Will a torn rotator cuff tendon heal on its own? We actually know the answer to this, and the answer is no. Tears in the rotator cuff do not heal with time. Studies show that even years after a tear is discovered, repeat MRI scans show there is no evidence of healing.

So we know the torn tendon doesn't heal.  Does this mean that I have to have surgery!?   If you want the tendon to heal, then the answer to this question is yes.  But consider this: many people live their entire lives with a tear in the rotator cuff, with no problems, and no or minimal pain.  So it is possible to live with a tear and do just fine.

In my practice, I generally recommend surgery for patients younger than 50 years old.  Between 50 and 65, it really depends on the patient: active people who need their shoulder for work or recreational activities should strongly consider surgery.   For patients over 65, I recommend surgery as a last resort, only if therapy and injections aren't helpful.

In summary, torn rotator cuff tendons do not heal and I recommend surgery for most patients younger than 65, especially those younger than 50.  Some patients older than 65 do well without surgery.

For more information about rotator cuff repair, see my previous blog posts.

Thursday, August 23

Live Shoulder Surgery Event

Me and Drew Osika  at the live surgery event yesterday
Thanks to those who participated in our live surgery event, held at Apollo Surgical in Brentwood, Missouri.  We'll be having more live surgery events in the coming months.    SSM Physical Therapy and Apollo Surgical co-sponsored the event.

Shoulder Replacement

I recently filmed a new video of a shoulder replacement surgery.  Shoulder replacement is an excellent option for patients who have severe arthritis and persistent pain.  Shoulder replacement is also an option for some patients with large rotator cuff tears.   Many patients with shoulder replacement will have no pain after surgery, while others will have a significant decrease in their pain.  Most patients will have increased strength and motion, as well.  There are risks to shoulder replacement.  If you have been told that you need a shoulder replacement, it is worth having a detailed discussion with your surgeon about the potential benefits but also the risks.

Wednesday, July 4

Dr. Frisella's Practice Intro Video

video 

The Barnes Hospital system produced this short video about my shoulder surgery practice, which includes interviews with some of my patients.  A heartfelt thank you to the people who took time out of their day to make this video possible.  Seeing patients talk about their results is a nice reminder of why I do what I do.

Missouri Division of Workers' Compensation Meeting

We had a great turnout for my talk last month at the Missouri Division of Workers' Compensation Annual Meeting.  I spoke about impairment and disability, and how I assign disability ratings in my practice.  I used videos to illustrate how I assess loss of strength and motion.  Generally, most patients who have a surgically repaired rotator cuff or labral tear will have about 5% permanent loss of strength and motion in their shoulder.  That means that, in the long term, they will get back about 95% of their "normal" strength and motion. 

Thursday, May 3

Say Goodbye to Shannon!

Many of my patients know my medical assistant Shannon Donati, who has been an integral part of my practice since 2007.  If you've been to see me, you've seen Shannon--wallking you in, explaining procedures, setting up tests and surgeries.  After five years of outstanding service to my patients, Shannon is moving on to a supervisor role at St. Peters Bone and Joint Surgery.  We will miss her! 

Thursday, March 1

Golf and Your Shoulder

Typical golf swing:
Notice the wide range of motion of the left shoulder
A shoulder injury is the second most common golfing injury (back injuries are the most common).  It might be a surprise to know that right-handed golfers have an increased risk of injury to the left shoulder.  That's because the left shoulder travels through a long motion during the swing, moving back with the backswing and forward with the follow-through.  This swinging motion puts strain on the rotator cuff and can cause tendonitis and bursitis.

If you shoulder is bothering you, what can you do?  My advice to most patients is first to take a week or two off.  If that doesn't work, then try to shorten your swing.  Try a shorter swing first at the driving range with your irons.  If that goes well and you can swing without pain, then move on to playing nine holes with only your irons.  If at any point pain returns, stop, take a week off, then try again.  If things don't improve, see a shoulder doc.

Happy golfing!

Thursday, February 16

Teaching at the Orthopedic Surgery Annual Meeting

My mentors Drs. Peter McCann and Fran Cuomo asked me to help teach a course on arthroscopic rotator cuff repair at the American Academy of Orthopedic Surgery Annual Meeting in San Franisco last week.  Great chance for me to reconnect with my shoulder surgery teachers and help others learn at the same time. 

Here's the course description:
http://www.abstractsonline.com/Plan/SessionPrintView.aspx?mID=2841&sKey=c6182178-f316-47eb-99c6-acc4e7bf23af&mKey=BA8AA154-A9B9-41F9-91A7-F4A4CB050945

Thursday, January 19

Simple Shoulder Exercises

Many shoulder problems will improve with simple exercises.  Nick Weber from Excel Physical Therapy was nice enough to volunteer to put together a brief video demonstrating a very basic set of five exercises that often help with many types of shoulder pain related to inflammation.  In my experience, about 75% of patients improve significantly with physical therapy.  Just a note:  if your pain is severe or the diagnosis is not known, consult a physician!

New Website

Check out the new website at doctorfrisella.com.

Thursday, November 3

Shoulder Dislocation: A Problem that Often Comes Back

I often see young patients who have dislocated their shoulder as the result of a sports injury.  Shoulder dislocations are common in young adults, especially in men.  Typically, the shoulder dislocates out the front.  We call this an "anterior shoulder dislocation".  Any time the shoulder dislocates it almost always causes a significant tear in the ligaments in the front of the shoulder.  We call this a "torn labrum", or a "Bankart tear."  These mean the same thing:  the structures are torn that normally hold the shoulder in place. 

In young people, a first time dislocation is often the precursor to multiple dislocations.  In other words, once you dislocate your shoulder once you are likely to dislocate it again.  Each time a shoulder dislocates, further damage is likely.  For this reason, the torn ligmanets must be repaired to minimize or eliminate the chance for more dislocations.  This surgery can easily be done arthroscopically as a same day procedure through three incisions. 

The recovery involves:
1) four to six weeks in a sling
2) eight to twelve weeks of physical therapy
3) six months before return to contact sports (football, soccer, hockey)

It is important to realize that a shoulder dislocation is different than a shoulder separation.  A dislocation means the ball comes out of the socket and generally requires a trip to the ER to put it back in place.  A separation is when the collarbone breaks free of the shoulder blade and causes a large bump on the top of the shoulder.  These are two very different problems!

Thursday, September 29

Missouri Self-Insurers Annual Meeting

I was able to talk last week at the Missouri Self-Insurer's Association 22nd Annual Conference.  My talk concerned the issue of causation in rotator cuff tears.  Not everyone knows that the tendons of the rotator cuff tend to tear over time, and that up to 50% of people in their 50's may have a tear in the rotator cuff.  This makes it difficult to determine with certainty if a work injury caused the tear or if it was a pre-existing condition.  Many thanks to Pat Venditti, MSIA president, for extending the invitation to speak.

Monday, August 15

Elbow Pain - What is "tennis elbow"?

If you have pain on the outside of your elbow, chances are it's tennis elbow.  Tennis elbow causes pain when you reach or grasp.  Getting milk out of the fridge, reaching to grab a cup of coffee and bringing it to your mouth:  these things can be exquisitely painful if you have tennis elbow.  You don't need to play tennis to get tennis elbow, and it can happen in your dominant or non-dominant hand.  Initial treatments are simple:  stretching, strengthening, and a forearm strap can all be helpful.  Cortisone shots almost always work for several months, but usually wear off.  The good news:  tennis elbow usually resolves on its own.  In some cases, surgery is necessary, but that's the case for very few patients.
 

Friday, August 5

Dr. Frisella YouTube Channel

Just launched a YouTube Channel with videos of the most common surgeries I perform.  I think it is a nice tool to allow patients to see what we'll be doing in the operating room.  You can watch the videos to the right of the blog or click here to view the YouTube Channel:  http://www.youtube.com/user/doctorfrisella.

Sunday, July 24

Ultrasound-Guided Injection Video

video
Here is a brief video of two ultrasound-guided injections.  The first is a subacromial injection around the rotator cuff tendon.  The second is an injection along the biceps tendon in the shoulder.  See my post below describing the advantages of ultrasound-guided injections.

Wednesday, July 20

Glazer's Tour



Matt, Shannon, and I at Glazer's in St. Charles

Today Shannon and I had the opportunity to visit Glazer's in St. Charles.  Glazer's is one of the largest beverage alcohol distributorships in Missouri.  They began operating in Missouri in 1997.  The company itself is more than one hundred years old, which is by itself remarkable.  Glazer's operation was impressive both in size and efficiency.  From my perspective, it is very helpful to see what people actually do in their day-to-day work in order to better manage their orthopedic injuries.  Our thanks to Matt Humphrey for the tour of the facility.  I can certainly say that I have never seen so much alcohol in my life! 

Monday, July 18

What's an ultrasound-guided injection?

Cortisone injections are very useful in managing the inflammation associated with shoulder pain, as I discussed in my last blog post.  Ultrasound provides the "eyes" for guiding the injection into the right part of the shoulder or elbow.  An ultrasound machine is just like the machine used to look at a baby in a pregnant woman:  it's a safe, painless way to look inside the body.  Ultrasound uses high frequency sound waves (kind of like a bat) to create a picture of the inside of a joint.  We can see distinct spaces inside the shoulder or elbow and use that picture to guide our injection.

Ultrasound-guided injections have several advantages over traditional injections:

1) more accurate
2) more effective
3) less painful

For instance, the shoulder is not a simple joint and consists of multiple separate spaces: 

1) the glenohumeral joint, or true shoulder joint, where the cartilage is
2) the subacromial space, or the area above the rotator cuff
3) the acromioclavicular joint between the clavicle and acromion
4) the biceps tendon sheath

A particular patient may need an injection into just one or two of these compartment.  Putting an injection into the wrong area decreases the chance that the injection will be helpful.  In the past, "blind" injections were used by feeling the shoulder and making a "best guess" as to where to place the cortisone.  Recent studies have shown that these injections are often inaccurate.  Ultrasound guidance greatly improves accuracy and has been shown  to provide better and faster pain relief.

The use of ultrasound also dramatically reduces the pain associated with the injection itself.  Because I can see exactly where I am placing the injection, the injection is quick.  Most patients get a feeling of fullness as the steroid is injected; also, the lidocaine used to numb the area can cause a burning sensation.  Both fullness and burning quickly go away after a few seconds.

The most common comment that most patients make after the injection:  "That wasn't bad at all!"

One thing I warn patients is that pain may actually increase for 12-48 hours after the injection.  Many patients will report that their shoulder or elbow hurts much worse for a day or two after the injection.  The cortisone takes a few days to start to work, and during that time the injected area may be even more inflamed than it had been.  During this time use ice, decrease your activity level, and take over-the-counter ibuprofen or tylenol.

Like any treatment, injection is not a cure-all.  Some patients do not respond to injection at all!  Others have permanent improvement in their pain.  Cortisone can sometimes be a "temporary fix" but often I find a permanent improvement in symptoms.  It's like putting out a fire:  if you extinguish every last ember, then the fire may go out for good.  That's why ultrasound guidance may be better:  you're putting the injection right where the fire is.

Hope that helps!

Saturday, July 2

Recovery from Rotator Cuff Repair

Since rotator cuff repair is the most common surgery I perform, a common question is:  "How long before I recover from a rotator cuff repair?"  The quick answer: 3 to 6 months.  Read below to learn more.

What is the rotator cuff?  The rotator cuff is a series of tendons around the shoulder.  Tears in the rotator cuff are common, especially after the age of 40.  Since the tendon does not heal on its own, surgery may sometimes be used to relieve symptoms of pain and weakness.  Surgery is arthroscopic, through small incisions, and generally causes minimal scarring.  However, the recovery from a rotator cuff repair is difficult  and takes many months!

There are three phases to recovery from rotator cuff repair surgery: 

First, the healing phase of recovery.  During this phase motion is limited and a sling must be worn.  Gentle physical therapy may be started, but no aggressive motion.  I allow patients to remove their sling while seated (for instance, while watching TV) and at night. In patients with small or partial tears, this phase may be as short as two weeks.  For larger, more complex tears, this phase may be as long as six weeks. 

Second, the motion phase.  During this phase the sling can be removed and aggressive physical therapy is started to restore motion.  During this time activity is generally limited to lifting less than 5 pounds and below chest level.  This phase generally lasts 4 to 6 weeks.

Third, the strengthening phase.  Once motion is restored, strengthening exercises are begun.  This phase may last another 4 to 6 weeks, during which time lifting is limited to 20 pounds.

Recovery time for most patients is about 4 months.  During this time many people will experience nighttime pain, stiffness, popping, catching, and feelings of tightness.  All of that is normal!  In fact, most people continue to experience symptoms for up to a year from the time of surgery.  You won't be 100% until one year from surgery.  It is important to understand this, otherwise the recovery can be very frustrating.

For work, most people with office jobs can easily go back to work after a 3-7 days.  The sling can be removed for typing and writing almost immediately.  For physical jobs return to work is much different.  In patients with very high demand jobs (carpentery, drywall installation, pipefitters, construction workers) return to full duty should be expected at 4-5 months from the time of surgery.

The most important thing that you can do to recover from your rotator cuff repair surgery is to be absolutely faithful to your physical therapy and absolutely religious about doing your exercises at home.  I am convinced that the best outcomes come to the patient who is most committed to their therapy.

If you are considering rotator cuff repair or have had the surgery, I hope this helps.

Thursday, June 30

Surgery Observation

Today in the OR had a visitor through my surgery observation program, Bob Daft from the Lear Corporation.  I hope Bob had a good experience today.

Thursday, June 23

MissOuri Smelting Technology (MOST) Site Visit


Jim Clements, myself, Lisa Angeles RN

This morning I had the chance visit Missouri Smelting Technology, or MOST, in Troy, MO.  I went with Lisa Angeles, RN case manager for one of my patients.  Jim Clements, the plant manager, did a great job of showing us what they do at MOST.  My sincere thanks to Jim for taking the time to show us around.  Also thanks to Katherine Shaw, the HR director, for setting everything up and allowing us to come out.  It was very helpful in allowing me to assess the physical demands of their work.  It was also just plain impressive.  Thanks again.


Wednesday, June 22

Can't sleep because of your shoulder?

Many shoulder problems cause difficult with sleep at night.  The #1 complaint that I hear in my practice is "I can't get comfortable at night."  In fact, my patients are often dragged in to see me by their spouse because their significant other tosses and turns all night.  Nighttime pain is often the most significant part of a problem with the shoulder.  Other complaints include difficulty with reaching above the head or behind the back, difficulty getting a bra on, or difficulty reaching into a back pocket.  Many times the pain radiates into the arm as well.
What causes nighttime pain?  One word: inflammation.  Inflammation is the root cause of many problems that affect the shoulder while resting.  Inflammation can  result from one of several different underlying problems.  Problems that cause inflammation include rotator cuff tendonitis or tears, "bone spurs", and arthritis in the shoulder.  Frozen shoulder also is the result of inflammation.  Of these, rotator cuff problems are the most common.
What can we do about it?  This time, it's a two word answer: cortisone shot.  Although cortisone injections are not the solution for every patient, they are often very helpful with nighttime pain.  They may completely eliminate the problem, permanently.  In other cases, they may help for weeks or months.  Besides cortisone shots, other treatments for shoulder pain are available.  These include anti-inflammatory medication and physical therapy.  Rarely, surgery may be necessary to correct a significant problem, such as a severely torn rotator cuff tear or large bone spurs which cause friction and rubbing.  For a very small group of patients with arthritis, shoulder replacement may be the best option.
A physical exam, x-rays, and sometimes an MRI are all necessary to establish a diagnosis.  Making an appointment when things have been going on for more than a week or two is often helpful to "nip it in the bud" and prevent the problem from getting worse.  Remember, it is not normal for a shoulder to be painful.

Afterword:  see my post about ultrasound-guided injections for more information!

Tuesday, June 14

Talk at the Missouri Division of Workers' Compensation Annual Meeting

Yesterday I had the pleasure of speaking at the Missouri Division of Workers' Compensation 17th Annual Meeting.  The subject of my talk was "Determining Causation in Rotator Cuff Tears".  The talk was a great chance to discuss the difficult question of what causes a rotator cuff tear.  Sometimes the cause is degenerative--wear and tear--and sometimes traumatic--from an injury.  I was happy to see many administrative law judges in the audience and had a chance to discuss the subject with several of them, including David Zerrer, Carl Mueller, and Tim Wilson.  I met the chief administrative law judge in St. Charles County, Grant Gorman, and have invited him to our practice to discuss issues in the law.

Thursday, May 26

Observation with Dr. Yamaguchi

Me and Dr. Yamaguchi
Today I had the opportunity to spend a day in the operating room with Dr. Ken Yamaguchi at Barnes Hospital in St. Louis.  It is nice to learn how another surgeon approaches shoulder replacement and I learned quite a bit from him.  Every surgeon  approaches a particular case differently and often seeing things done a different way stimulates me to consider how I could make my surgical outcomes even better.  Medicine and shoulder surgery, like all fields, is constantly changing.  Being able to discuss cases with a surgeon who is at the cutting edge of his field was a pleasure.  My thanks.

Friday, May 20

Meaningful Use

Congratulations to our office staff for meeting meaningful use criteria.  "Meaningful use" means that we are meeting and exceeding government requirements to use an electronic medical record.  Most practices still use paper charts.  We are staying ahead of the curve as usual!

Thursday, May 19

Teaching for the American Shoulder and Elbow Surgeons

I'm preparing to leave for Chicago where I'll be a faculty instructor in shoulder surgery for the American Shoulder and Elbow Society.  I was invited by my mentor, Dr. Peter McCann, the chair of orthopedic surgery at Beth Israel Medical Center in New York.

Tuesday, May 17

Recycle City

Today our staff toured Recycle City in St. Peters, one of the only municipal recycling centers in the state.  A great opportrunity to see what our community is doing behind the scenes.  We also toured the Lear manufacturing facility in Wentzville.  I am impressed by what they have been doing with ergonomics to decrease workplace injuries.