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

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

The Orthopaedic Institute Welcomes R. James Toussaint, M.D. in Gainesville

by TOI Admin September 2, 2014

 

The Orthopaedic Institute announces that R. James Toussaint, M.D., has joined its group of 29 fully trained, experienced, specialty physicians providing the complete spectrum of muscle, bone and joint care.

TOI has four full service clinics throughout North Florida. Dr. Toussaint is based out of The Orthopaedic Institute's Gainesville office, located at 4500 Newberry Road.

Dr. Toussaint graduated from the New York University School of Medicine, completed his Orthopaedic Surgery Residency at Harvard Medical School, and recently concluded his Foot and Ankle Fellowship Training at OrthoCarolina Foot and Ankle Institute. Dr. Toussaint is board eligible with areas of clinical interest in Degenerative, Traumatic and Sports Related Foot and Ankle Disorders.

Dr. Toussaint is a member of the Alpha Omega Alpha Honor Medical Society, American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society.

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Foot & Ankle

Football Injury Prevention

by TOI Admin August 27, 2014

Football is the leading cause of school sports injuries. According to the U.S. Consumer Product Safety Commission, in 2012, approximately 1,242,491 people were treated for football-related injuries in hospital emergency rooms, doctors' offices, and clinics.

Proper Preparation for Play

  • Maintain fitness. Be sure you are in good physical condition at the start of football season. During the off-season, stick to a balanced fitness program that incorporates aerobic exercise, strength training, and flexibility. If you are out of shape at the start of the season, gradually increase your activity level and slowly build back up to a higher fitness level.
  • Pre-season physical. All players should have a pre-season physical to determine their readiness to play and uncover any condition that may limit participation.
  • Warm up and stretch. Always take time to warm up and stretch, especially your hips, knees, thighs and calves. Research studies have shown that cold muscles are more prone to injury. Warm up with jumping jacks, running, or walking in place for 3 to 5 minutes. Then slowly and gently stretch, holding each stretch for 30 seconds.
  • Cool down and stretch. Stretching at the end of practice is too often neglected because of busy schedules. Stretching can help reduce muscle soreness and keep muscles long and flexible. Be sure to stretch after each training practice to reduce your risk for injury.
  • Hydrate. Even mild levels of dehydration can hurt athletic performance. If you have not had enough fluids, your body will not be able to effectively cool itself through sweat and evaporation. A general recommendation is to drink 24 ounces of non-caffeinated fluid 2 hours before exercise. Drinking an additional 8 ounces of water or sports drink right before exercise is also helpful. While you are exercising, break for an 8 oz. cup of water every 20 minutes.

 

Ensure Proper Equipment

Protective equipment is one of the most important factors in reducing the risk of injury in football. According to Pop Warner Football, Official Rule Book, players should have the following protective gear:

  • Helmet
  • Shoulder pads, hip pads, tail pads, knee pads
  • Pants (one piece or shell)
  • Thigh guards
  • Jersey
  • Mouth guard (A keeper strap is required.)
  • Athletic supporter
  • Shoes (In some leagues, players can wear sneakers or non-detachable, rubber cleated shoes. Detachable cleats of a soft-composition also are allowed in some leagues. Check with your coach about the type of shoe allowed in your league.)
  • If eyeglasses must be worn by a player, they should be of approved construction with non-shattering glass (safety glass). Contact lenses also can be worn.

 

Prepare for Injuries

  • Coaches should be knowledgeable about first aid and be able to administer it for minor injuries, such as facial cuts, bruises, or minor strains and sprains.
  • Be prepared for emergencies. All coaches should have a plan to reach medical personnel for help with more significant injuries such as concussions, dislocations, contusions, sprains, abrasions, and fractures.

 

Safe Return to Play

An injured player's symptoms must be completely gone before returning to play. For example:

  • In case of a joint problem, the player must have no pain, no swelling, full range of motion, and normal strength.
  • In case of concussion, the player must have no symptoms at rest or with exercise, and should be cleared by the appropriate medical provider.

 

Additional Guidelines

Here are some additional strategies for parents and coaches to help young athletes prevent back-to-school sports injuries:

  • It is important for your child to stay active during the summer, so that he or she is prepared to begin participating in fall sports.
  • During practices, have children take frequent water breaks to prevent dehydration and overheating.
  • Learn to recognize early signs of pain and discomfort in children, and teach children to be aware of those signs as well. Let them know they should notify their coach or parent as soon as they experience any pain.
  • Avoid the pressure that is now exerted on many young athletes to overtrain. Listen to your body and decrease training time and intensity if pain or discomfort develops. This will reduce the risk of injury and help avoid “burn-out.”

 

 

Source: http://orthoinfo.aaos.org/topic.cfm?topic=a00113

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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