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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

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.