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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: