Shoulderdoctor

BICEPS - CUT OR REPAIR? . Biceps pathology can cause significant pain. It can either be the main problem or secondary to rotator cuff problems. Usually, rebalancing the shoulder with physical therapy can resolve this but sometimes it can progress. Depending on the cause surgery can sometimes be the right course of action. . Surgical options can be repair of its attachment (Labral repair), cut it and reattach to the upper arm (tenodesis) still in the shoulder joint (intraartic...ular) or in the upper arm (subpectoral), and tenotomy (cut it loose). . If you are going to cut the biceps it seems nonsensical to just leave it loose however apart from the 30-40% chance of cosmetic deformity, the pain can go immediately post op and the patient can mobilise immediately. . Tenodesis, in comparison seems more sensible but approximately 30% of patients still have pain post op and this pain can continue until the tenodesis finally fails. . The decision should always be made on discussion with the patient about their goals. . This paper shows that there is not much difference in post-op strength and functionality between the two methods. Counterintuitive as it may be, in this case repair may not always be the best route.
See More

I read an article by @ted recently which discussed how you could “prevent unnecessary medical care by asking your doctor these four questions”. Personally I think it’s good practice to discuss these in any case, and that the more information patients have the better informed their decision making. . What other questions would you recommend for patient consultations? Leave a comment below.👇

ATTRITIONAL OR ACUTE? . This is a great video demonstrating the anatomy of a RC tear, however it shows a very sped up version of the events. In reality, RC tears which “ping off” are more acute than degenerate (occurring over time due to chronic inflammation or irritation of the rotator cuff). . Understanding this is key to understanding why catching this early makes conservative treatment options more likely to work and why surgery might be a more likely recommendation in an... acute tear. . In balance, acute (traumatic) tears in the younger patient are more likely to need surgery than degenerate tears in the older patient. . In my practice we always recommend conservative treatment options and discuss the importance of good physical therapy even if we do proceed with surgery. 🎥: @3d4medical
See More

GOING ON HOLIDAY? . It’s peak holiday season and many of my patients are away (as am I). I’ve had a few requests for “fit to fly” letters for patients under my care and I always guide patients on the precautions to take when flying post-op. . Generally, flying post-op is safe if patients are aware of the risks and manage them. For my patients I normally advise at least a week after an operation to allow any side effects of general anaesthetic (if they have had this - many ope...rations are now “awake” and don’t need a general anaesthetic) to wear off, for them to be comfortable in a sling and for pain to be at a manageable level. . There is a heightened risk of deep-vein thrombosis (DVT) after surgery which vary from patient to patient and should be discussed in with the patient’s operating surgeon or GP. This helpful video by @henry_stax is a useful reminder of how a DVT forms. . Measures to help mitigate this risk include staying well hydrated on the day of and day after each flight, moving around the plane and performing small elbow, wrist and hand movements as shown by the post-op physical therapist and taking an Aspirin if recommended according to the patient’s medical history. . Generally the risk of DVT after shoulder and upper limb surgery is low (less than 1%*) but it’s important patients are aware of it. . In addition to this the general post-op precautions still apply - many patients forget that they are still recovering from an operation when they are in sunnier climes! . Wishing anyone travelling this summer while recovering from an operation safe and happy holidays! . *Thromboembolic Phenomena After Arthroscopic Shoulder Surgery, Kuremsky et al. 2011 Venous thromboembolism incidence in upper limb orthopedic surgery: do these procedures increase venous thromboembolism risk?, Hastie et al. 2014
See More

ARE ULTRASOUND SCANS EFFECTIVE IN DIAGNOSING RC PATHOLOGY? . I was interested to read this paper which suggests: . - ultrasound scans are an effective tool for diagnosing RC tears;... - The quality of the scan, machine and radiologist all make a difference; - The interpretation of the scan is best when there is dialogue between the radiologist and referring surgeon. . None of this is a surprise to me as I work with and rely on an excellent team of highly skilled radiologists who specialise in musculoskeletal problems and look at imaging all day, every day. . While most imaging is performed consistently the interpretation of that imaging takes a trained eye. . We will sometimes ask you to bring in your past imaging so that we can have the same radiologist compare this to more recent imaging reports. This is to allow comparison on the same basis and by the same person - an important check for progress or deterioration. . In my practice we also offer a one-stop service so that you can be seen, scanned and a diagnosis given to you at the same appointment rather than having to wait.
See More

ANYONE FOR TENNIS (ELBOW)? . With Wimbledon being at the forefront of sport in the summer many of us are inspired to pick up our rackets. . Tennis elbow is a condition that causes pain around the outside of the elbow. It's clinically known as lateral epicondylitis. It’s not always related to playing tennis though.... . It often occurs after strenuous overuse of the muscles and tendons of the forearm, near the elbow joint - it’s not just tennis players who can suffer from this condition! . Symptoms of tennis elbow include, but are not limited to: . - Pain, burning, or stiffness that gradually worsens over time. . - Pain in the outer elbow, radiating to the forearm, wrist, and/or fingers that starts out as an intermittent nuisance and then intensifies and becomes more constant. . - Pain that increases with activity but improves with rest. Many types of athlete, as well as anyone who relies on heavy use of repetitive arm and/or hand motions in their daily occupation, are at risk for developing tennis elbow. . - Additional causes and risk factors for tennis elbow include, but are not limited to: . - Age. People age 30 and older are at increased risk of developing tennis elbow. The risk accelerates even more after age 40. . - Not warming up before strenuous activity. Muscles and tendons are more pliable and less prone to tear when athletes stretch and warm up before engaging in intense sports or physically demanding work. Failing to do so can increase the risk of tissue damage that can lead to tennis elbow. . - Improper use of sports equipment, such as a tennis racket that is too small or too large for the athlete, or a racket that is not strung properly (for example, the head surface is too tight or too loose, or the racket is too heavy for the user). . - Poor athletic technique, such as when tennis players use hitting force that is supported mostly by the elbow rather than the core (abdominal) muscles.�. - Recent use of certain medications, such as fluoroquinolone antibiotics (Cipro, Levaquin, Avelox). . - Direct trauma to the elbow, such as colliding with another player or falling onto the elbow. . - Working in physically repetitive occupations.
See More

PRE-OP QUESTIONS . If you’re having an operation at what point should you be asking questions about the operation? . In my practice, patients are counselled about all the options open to them and where appropriate we always try conservative measures first. If conservative measures fail we discuss surgery. So when is the right time to ask questions?... . The answer for me is that you should feel comfortable with a treatment plan, especially when it involves surgery, well before the day of the operation. . We do everything we can to make patients comfortable, both on the day of surgery but also before and this should include making sure they understand exactly what they are having done and why. . If a patient is unsure, or has questions, I always counsel them not to proceed with surgery until they are absolutely sure. It’s not my practice to talk people into or out of surgery, rather we discuss all options and what’s right for that particular patient and then move forward.
See More

SHOULDER SUBLUXATION AFTER A STROKE . Last year I saw a stroke patient who was in his 40s who came to see me because of shoulder pathology. He had had a difficult time following his stroke and in the course of his treatment, his shoulder symptoms had not been explained to him. He was concerned that he might need surgery for his shoulder as well as having to deal with the stroke rehab. Even in my own family, my experience has been that shoulder symptoms are often not recognise...d following a stroke. . In patients who have had strokes, the muscles in the affected limb become weakened and this changes the biomechanics of the shoulder joint often causing shoulder subluxation. The muscles of the shoulder normally work together and in harmony to keep the numeral head centres in the socket, and when one or more muscle is weakened this balance can be affected. . The good news is that shoulder subluxation often resolves without surgical intervention but needs good rehab. . All rehab after a stroke is difficult and a hard slog but early and effective rehab is the best route to a good recovery and better quality of life.
See More

TRAINING PAIN . This is a useful graphic by @dr.caleb.burgess about training and pain. . Many patients will be concerned that their normal training regime is disrupted due to the need for rest and activity modification following an injury. When they do return to training it’s often difficult for them to judge how much pain is to be expected if any.... . I always advise patients to be guided by their physical therapist and to go slow and build up. . There’s no rush, and although recovery from injury may feel like it takes a long time, in the long term it’s well worth doing your physical therapy “homework” and building up to training again gradually.
See More

INJECTION INFECTION . I have a particular bugbear about patients who have steroid injections and are not warned about all the possible risks and complications. . I’ve previously posted about a potential increased risk of retear in rotator cuff repairs in patients who have had a preop steroid injection.... . This recent paper shows that the risk of infection is also increased in patients who have had a steroid injection in the month before a rotator cuff repair. This means that (particularly in large traumatic cuff tears) the operation would have to be delayed, potentially worsening an outcome. . Steroid injections are not benign. . While they are often a useful adjunct to therapy, it is incumbent upon all practitioners to appropriately counsel their patients about ALL the risks and complications, including the closing of potential doors in terms of treatment options open to them.
See More

THE ROTATOR CUFF MUSCLES . It’s a common misconception among patients that there is a single “rotator cuff muscle”. This is a great series of illustrations and original post by @pheasyque showing the individual rotator cuff muscles and what they do which helps to demonstrate how these individual muscles work together to keep the shoulder in joint. . The supraspinatus muscle performs abduction of the arm, and pulls the head of the humerus medially towards the glenoid cavity. I...t independently prevents the head of the humerus to slip inferiorly.⁣ ⁣. The infraspinatus and teres minor rotate the head of the humerus outward (external, or lateral, rotation) and they also assist in carrying the arm backward.⁣ ⁣. Lastly, the subscapularis rotates the head of the humerus medially (internal rotation) and adducts it. ⁣ ⁣. Since these muscles keep the head of the humerus in place within the glenoid fossa of the scapula and work synergistically with other muscles to allow movement, this means that when we move our arms in space, even the scapula will have to move/tilt and allow enough space for the head of the humerus to move "freely". ⁣ ⁣. This means there's a correlation between the movement of the arm & the scapula which will have to move together to allow functional moving patterns. ⁣
See More

AWAKE SURGERY? . Google “awake surgery” and you will almost certainly be presented with a series of horror stories about patients waking up in the middle of their surgery. . This is not the aim of “awake surgery”! Awake surgery is also not only limited to the brain.... . In my practice we have been using this technique for over 5 years with great success. There is no general anaesthetic involved. . The advantages are: - no risk of a general anaesthetic - minimal post-op pain - no side effects from an anaesthetic (post-op nausea and vomiting, drowsiness, confusion) - minimal, if any requirement for post-op opioids - patients can start immediate post-op physio . Some patients don’t like the idea of being fully awake to watch their operation from start to finish and for these patients we offer sedation so they can snooze away in comfort.
See More

HUMILITY IS KEY . I came across this diagram recently via @rooted_project and although it’s not a new concept I didn’t know it was called the Dunning-Kruger effect. . From Wikipedia: “this describes a cognitive bias in which people mistakenly assess their ability as greater than it is. It is related to the cognitive bias of illusory superiority and comes from the inability of people to recognize their lack of ability”.... . In basic terms a little bit of knowledge can be dangerous and may give a false sense of confidence. . In my practice I am careful to check and double check my understanding with colleagues and peers. A multi-disciplinary team-based approach ensures we hold each other to the highest standards ensuring better options and outcomes for our patients.
See More

MYOTOMES . Here’s a fun one for a Tuesday! . We all need to test myotomes as part of neurological examination in the course of our clinical practice and this video shows the basic tests for each myotome.

SHOULDER PAIN AND QUALITY OF LIFE . This is an interesting paper on shoulder pain and quality of life, specifically that shoulder pain impacts quality of life more than perhaps other types of musculoskeletal pain (the study considers knee pain, sciatica and low back pain). Further, a shoulder pain score on visual analogue scale was also significantly related to poor mental quality of life. . This is interesting and perhaps can be explained by the fact that many people sufferi...ng shoulder pain experience trouble sleeping. Over a period of time this can have an impact on the patient’s quality of life. . Our job as healthcare practitioners is to help people regain their quality of life as quickly as possible and the sooner a patient goes to see a doctor, physical therapist or consultant the better. . If shoulder pain is troubling you and has not resolved over a period of time it’s always worth getting it checked out.
See More

CALCIFIC TENDONITIS . Calcific tendonitis (or tendinitis) occurs when calcium deposits build up in your muscles or tendons. Although this can happen anywhere in the body, it usually occurs in the rotator cuff. . If you do feel pain, it’s likely to be in the front or back of your shoulder and into your arm. It may come on suddenly or build up gradually. Many of my patients present with sudden pain which can be excruciating.... . An X-ray can reveal larger deposits, and an ultrasound can help locate smaller deposits that the X-ray missed. . For deposits which don't go away by themselves, barbotage and needling can help to disperse these deposits. 😷 💉 . After administering local anesthesia to the area, a radiologist will use a needle through the skin to manually remove the deposit. This is done under ultrasound guidance to help guide the needle into the correct position. . The video shows surgical removal of a larger deposit. Only 10% of so of patients will need surgery, where desposits cannot be removed in an outpatient. . In all cases, good physical therapy is always recommended.💪
See More

GETTING DRESSED AFTER YOUR OP . Most patients who have shoulder operations usually don’t know what to expect in terms of how wearing a sling will affect their ability to get dressed post-op. . Usually we advise:... - loose t-shirts - Pull on, elasticated trousers, such as tracksuit bottoms - Front opening outerwear such as a hoodie . The nursing staff in the hospital will help you to get dressed initially and show you how to do this before you go home but the video above is a useful reminder. . Generally, remember to put your operated limb into clothes first, and to work with gravity (let your arm hang and slide clothes on to it). . Remember, dressing this way won’t be forever and you will soon be out of a sling and able to dress more normally!
See More