Treatment Options for Rotator Cuff Tears

by TOI Admin October 8, 2014

By Jonathan R. Pritt, M.D.

The rotator cuff is the anatomic name of a set of tendons in the shoulder that are critical to normal shoulder function and strength.  There are four muscles that converge to form the rotator cuff.  They originate from the scapula or shoulder blade.  These muscles cross the shoulder joint and turn into a cuff of tendon tissue that attaches to the humerus bone on the front, top and back of the shoulder joint.  As the name suggests, these muscles play an important role in the rotation and motion of the shoulder joint in all planes. 

The rotator cuff can tear as a result of injury or, much more commonly, as a result of age related degeneration.  If the tear is small, the symptoms can be minimal or can result in significant pain when the shoulder is put to use.  Pain at night is extremely common and is often the reason patients decide to see a physician.  A larger tear can cause pain and significant weakness when the arm is used away from the body or overhead. 

Chronic changes that occur as a result of a rotator cuff tear can be seen on simple X-rays of the shoulder.  However, an MRI is often needed to appreciate smaller tears or sudden tears of the rotator cuff.  A spectrum of tear patterns and progression can be seen on an MRI, from small tears and partial fraying of the tendons to massive tears that are no longer repairable.  The treatment options vary depending on the size and progression of the tears. 

Treatments of rotator cuff tears include specialized physical therapy to strengthen the rotator cuff, steroid injections to minimize pain around the rotator cuff, and surgery to repair the cuff and remove any unhealthy tissue from the area. 

If an individual has a rotator cuff tear that is symptomatic and the primary symptom is pain with use and/or pain at night during sleep, then that person could anticipate an 80% chance of significant pain improvement with a steroid injection and formal physical therapy.  Therapy can take up to 12 weeks to improve pain symptoms.  Therapy focuses on retraining the muscles around the shoulder so that they work in proper dynamics.

Steroid injections around the rotator cuff act as a potent anti-inflammatory to the area of the rotator cuff and surrounding tissues that can become inflamed.  Injectable steroids are molecules related to cortisone, which is the body’s native regulator of inflammation.  These injections offer a high percentage chance of pain relief for a period of time but do not replace the need for physical rehabilitation of the shoulder.  Steroid injections have very low infection risks or other side effects.  Although these injections do have a low risk of infection, they tend to increase blood sugars in patients with diabetes.

When surgery is required to address rotator cuff disease, it falls under two broad categories - debridement or repair. 

Debridement is an option for small, partial thickness, tears of the rotator cuff or in the situation of an irreparable tear in some individuals.  Debridement means removal of tissue that is unhealthy and irritated.  This is usually done arthroscopically through small poke holes in the skin where small instruments can be placed in and around the joint to see and perform the necessary work.  With this procedure, post-operative recovery is accelerated, requiring only a few days in a sling for comfort followed by physical therapy. 

On the other hand, if the rotator cuff is surgically repaired, then recovery is more limited. 
Rotator cuff repair can be done arthroscopically or through an open incision depending on the surgeon’s preference.  Recovery after rotator cuff repair is typically 4-6 weeks of sling protection, 6-8 weeks of therapy for range of motion, and 3 months of strengthening.  Surgery offers an 80-85% chance of good to excellent pain relief. 

In the situation of large or massive irreparable rotator cuff tears that also develop significant arthritis, a specific type of joint replacement surgery may be an option.  This is called reverse total shoulder replacement.  Reverse total shoulder replacement “reverses” the normal ball and socket geometry of the shoulder joint to help replace some of the function of the rotator cuff.  This surgery offers a high percentage of pain relief and improvement in function.

Rotator cuff disease is a very common cause of shoulder pain.  There are good surgical and nonsurgical options for treatment of rotator cuff problems.  Treatment choice is based on individual factors and disease severity.  It is best to consult with an orthopaedic physician with any questions or concerns regarding shoulder pain.

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Shoulder

National Physician Assistant Week, October 6th - October 12th, 2014

by TOI Admin October 6, 2014

National Physician Assistant Week is held every year from October 6th-12th to celebrate the PA profession and also increase awareness of the importance of a healthy lifestyle.
TOI would like to give a special thank you to its PAs at all locations! To learn more about National PA Week, please click here.

Physician Assistants
Kris Andrews
Alex Rangel
Vance Amos
Christina Goodwin
Dustin Lilly
Harley Wernon
Dave Wooley

October is recognized as National Physical Therapy Month!

by TOI Admin September 30, 2014

The month of October is recognized as National Physical Therapy Month by the American Physical Therapy Association. National Physical Therapy Month helps recognize the impact that physical therapists and physical therapist assistants make in restoring and improving motion in people’s lives. TOI would like to give a special thank you to its physical therapy staff at all of its locations!

 

Physical Therapists: Physical Therapy Assistants:
Herb Anding Carlos Boston
Chris Follenius Melissa Cobb
Sam Goldstein Jason Guynn
Dale Hughes Chris Lacy
David Lee Jessica Langley
Joyce Shahboz John Sherman
Carrie Waldren Kyle Sykes
Christy Yaxley  
 
Physical Therapy Staff:
Physical Therapy Techs: Treasia Desena
Chad Awad Kaitlyn Franklin
Thad Boucher Madison Karelas
William Cobb Tera Kelley
Joey Edge Hannah Knighton
Ashley Malphurs Beverly Lasseter
Jeronica Roundtree Jamie Latsko
Steven Spence Rich O'Steen
Kelli Thomas Kristin Skipper
 

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General Information

Common Causes of Finger Stiffness

by TOI Admin September 22, 2014

By Zakariah S. Mahmood, M.D.

A common complaint of patients who are referred to a hand specialist is loss of mobility and motion of the fingers. Most often these complaints are gradual in onset, rather than starting abruptly. The stiffness and loss of mobility may or may not be associated with pain. Usually, patients complain of the inability to do activities they enjoy because of loss of gripping ability or fine dexterity. Important and common causes of this loss in mobility include Dupuytren's contracture, arthritis, locked trigger finger, and various injuries. Fortunately, there are treatments available for these conditions. The following article describes the common causes and treatment options for finger stiffness.

Dupuytren's Contracture

The palm of the hand contains many important structures that allow the hand to function normally. Very small nerves travel next to tendons and muscles, allowing the hand and fingers to create function. To help bind, cushion, and separate these structures, there is a thick layer of connective tissue called the palmar fascia.  It is similar in appearance and texture to gristle found in meat. Normally, this layer is not visible nor necessarily palpable from the skin surface. It is this layer that develops a scar (fibromatosis) in Dupuytren's contracture.

Dupuytren's causes a contracture or bending of the fingers into the palm. Typically there can be demonstrable cords in the palm and fingers that act as tethers, which keep the fingers from opening up all the way. Occasionally, these cords can be accompanied by small pits or nodules in the skin. Patients typically seek help when the amount of tethering interferes with daily activities such as shaking hands, putting the hands in the pockets, or fine manipulation. It is also possible that the cords can interfere with grip. Typically, the cords do not cause pain. Dupuytren's contracture is a genetic disorder that is most often found in people of northern European ancestry, but can effect anyone. It can occur in one or several areas of the hand and fingers and at nearly any age. The severity and progression vary from person to person and cannot be accurately predicted, but the speed of previous progression and previous responses to treatments can serve as general guides.

Treatment is focused on allowing the fingers to straighten out and restoring function. This can be done surgically by excising (removing) the cords in the palmar fascia, incising (cutting, but not removing the cords), and Xiaflex injections. These are specific injections which work to dissolve the cord, allowing the finger to straighten out without surgery. There are various advantages and disadvantages to each of these treatments, and your orthopaedic hand specialist can help you decide which is best for you based on your pattern and severity of Dupuytren's contracture.

Trigger Finger (Stenosing Tenosynovitis)

Trigger finger, or stenosing tenosynovitis, is a common condition and can cause a stiff finger. In a normal finger, there is a 'tunnel' made up of a system of pulleys throughout the finger, which the tendon glides through. When there is swelling, from any number of causes, the tendon can catch at the opening of the tunnel. For example, this is similar to a thread which can be typically be pulled back and forth easily through the eye of a needle, but when there is a knot on the thread, it gets caught at the eye of the needle. Like in trigger finger, when this knot/swelling is big enough, the tendon can actually get caught in the tunnel. There are other, more rare conditions that can be mistaken for a locked trigger finger, and these must be kept in mind when considering a diagnosis. A trigger finger usually presents pain, locking or catching of the finger when moving it, and occasionally a permanently bent finger.

Trigger fingers can be treated with steroid/cortisone injections as a first line of treatment. There is a success rate of up to 75% after a single injection. Splinting the finger in extension is also a treatment option, but these splints are often poorly tolerated and can be cumbersome and uncomfortable to wear, so are not typically offered. A final option is surgical treatment. With surgery, a small incision is made at the edge of the tunnel and it is 'opened' so that the tendon does not get caught. With the needle and thread analogy, this is similar to widening the eye of the needle, allowing the knot on the thread to easily move back and forth. Surgery is typically a permanent fix for this problem.

Arthritis

It should be apparent that stiffness in the finger or hand is not always arthritis, but arthritis still remains an important cause of finger stiffness. Arthritis is the loss of cartilage that covers the end of the bones, which allows for smooth motion at the joints. It can be caused by a multitude of reasons, including genetics, wear and tear, and injuries, such as fractures. Typically, but not always, arthritis is accompanied by pain in the joints and swelling. Bone spurs can develop and widen the joints, causing misshapen fingers.

Treatment of the arthritis is based on location. NSAIDs (nonsteroidal anti-inflammatory drugs) such as ibuprofen, aspirin, and naproxen, can be helpful in early stages. As the arthritis progresses, they typically become less effective. Steroid injections are stronger anti-inflammatory medications that can be injected into joints to give relief from the symptoms of the arthritis. Depending on the location of the arthritis, splints or braces can also help. Specifically, thumb base arthritis can be helped with individualized braces. When activity modification, NSAIDs, steroid injections, and splinting fail to help, surgery can be considered as an option to treat arthritis.

Surgery for arthritis in the fingers varies based on the location of the arthritis. One surgical option is when the larger two joints in the finger, between the Proximal Phalanx and the Middle Phalanx, are fused. Another surgical option is to have a small joint replacement. A fusion procedure keeps the problem finger joints from moving so that pain is eliminated. Joint replacements aim to maintain or improve range of motion and eliminate pain. The smallest joints at the tip of the finger, between the Middle Phalanx and Distal Phalanx, are usually fused when the arthritis fails to respond to other treatments. This eliminates pain and restores a more normal appearance at the tip of the finger, however, this is also at the expense of motion.

Finally, thumb base arthritis, located between the Trapezium and the 1st Metacarpal Bone, has many surgical remedies. One surgical treatment for thumb arthritis is similar to a hip arthritis, where the arthritis is eliminated by removing the head of the femur (thigh bone) and then replaced using a metal implant. In thumb arthritis, a portion of the bone at the base of the thumb or the entire bone is removed, eliminating the arthritis. Usually, a suture or a tendon from the wrist area can then be used to replace the missing bone rather than a metal implant.

Other important causes of finger stiffness and loss of motion include old tendon injuries, sprains, and fractures that have healed incorrectly. These should always be considered among other possibilities for a stiff finger. If you are experiencing finger stiffness, ask your orthopaedic hand specialist about your particular diagnosis and treatment options available to you.

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Finger

Keeping You BodyWise: A New Way For Partial Knee Replacements

by TOI Admin September 15, 2014

A New Way For Partial Knee Replacements

By Timothy Lane M.D.

The goal of knee replacement surgery is to decrease pain and restore function in the knee. Although most knee replacement candidates need a total knee replacement, there is a percentage of patients who qualify for a less invasive option.  This less invasive option is called an unicompartmental knee replacement, better known as  “partial knee replacement.” Partial knee replacement is a procedure that surgeons have used to treat knee pain for approximately 30 years.  A partial knee replacement replaces only the worn portion of the joint. It is used in individuals in whom the wear is confined to one part of the knee – usually the inner or medial side.  Therefore, the surgery is localized to the worn joint surface and involves minimal additional surgery on the knee such as ligament surgery.  In contrast, total knee replacement replaces all three wearing surfaces of the knee (the lower end of the femur, the top surface of the tibia, and the back surface of the patella) and involves more extensive surgery on the supporting ligaments.  Total knee replacement is the appropriate choice for individuals with more severe arthritis, while partial knee replacement is appropriate for individuals with more localized wear on the knee joint. 


What are the advantages of partial knee replacement?

Because partial knee replacement is a more limited procedure than a total knee replacement, it can result in a more
natural-feeling knee.  In a partial knee replacement, the surgeon resurfaces only the diseased portion of the knee, thus preserving the healthy bone and tissue. This can potentially lead to a faster recovery and lower risk of complications such as infection, blood clots, and knee stiffness. 


Who is an appropriate candidate for this procedure?

Surgery for arthritis of the knee is typically performed when non-surgical forms of treatment such as medication, injection, and exercise do not provide acceptable relief of the arthritic pain.  Patients who are candidates for partial knee replacment usually experience activity-related pain in the inner side of the knee.  Startup pain, limping, and pain when standing and walking is common for potential candidates.  Because partial knee replacements are performed in
patients with less severe arthritis than total knee replacements, patients undergoing these procedures have less preoperative loss of motion than patients undergoing full knee replacement surgery. In addition, their preoperative X-rays show less severe and more localized arthritic changes in the knee.

What is the MAKOplasty partial knee replacement?

MAKOplasty partial knee replacement is a new surgical procedure utilizing robotic technology to accomplish consistent precision surgery in reconstructing damaged joints. The MAKO device uses a preoperative CT scan to assess the bony structure and alignment of the knee.  The Robotic Arm Interactive Orthopedic System (shown on the previous page) then allows the surgeon to preoperatively plan the procedure.  The surgeon can assess the sizing, positioning, and function of the partial knee preoperatively.  During the surgery, the device can confirm that the components are appropriately positioned and functioning.  The surgeon-controlled Robotic Arm Interactive System is then used to precisely remove the worn joint surface to prepare the area for placement of the partial knee.  It is this combination of CT-guided preoperative planning and surgeon-controlled robotic removal of bone that allows the operation to be done in a very precise manner.  This new technology represents a powerful tool to assist the surgeon in performing more accurate and reproducible surgeries. This optimal placement can result in a more natural motion of the knee following surgery.


Are there potential complications from partial knee replacement surgery?

Even though partial knee replacement is considered a minimally invasive procedure, there are still risks associated with the surgery.  Although rare, blood clots are the most common complication after surgery. Other complications include infection, implant loosening, fractures and nerve or blood vessel damage. The main disadvantage of a partial knee replacement is the potential need for more surgery in the future. If osteoarthritis progresses to the other compartments of your knee, a total knee replacement “revision surgery” may be necessary.

In summary, a MAKOplasty type partial knee replacement provides a valuable additional alternative for patients with knee arthritis. It is important to discuss the specific risks associated with MAKOplasty and other treatment options with your orthopaedic surgeon.

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Knees | MAKO

Welcome to TOI's Blog!

TOI's Blog is dedicated to patient education with topics addressing current issues in health and medicine. We will also blog about some of our other favorite things, like community events, our wonderful employees, helping the environment and whatever else comes to our minds! We hope the information contained in our blog is fun to read, assists you in making educated decisions regarding your health, and supports your decision to select TOI when you are in need of quality musculoskeletal care.

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