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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.