Category Archives: Shoulder

Is Physical Therapy Effective After Rotator Cuff Tear?

shoulderptDr. Stickney, a Kirkland orthopedic surgeon, is an expert in shoulder injury treatment, total and partial knee arthroplasty, sports medicine, and more. 

Rotator cuff tears can occur from athletics such as baseball, weightlifting, competitive swimming or just over time with overuse and improper strength and flexibility. These shoulder injuries are extremely common, affecting at least 10% of people over the age of 60 in the United States – which equates to over 5.7 million individuals. Of the 5.7 million+ individuals who suffer from rotator cuff tears, fewer than 5% are treated surgically, and patients who undergo surgical repair experience a failure rate between 25 and 90%. What’s interesting though, is that patients with repair failures report satisfaction levels and outcome scores that are nearly indistinguishable from those whose repairs are intact. Because most of these surgical patients undergo postoperative physical therapy, it is logical to assume that physical therapy may be responsible for the improvements in outcome. A multicenter prospective cohort study conducted by the MOON Shoulder Group and published by Journal of Shoulder and Elbow Surgery takes a closer look.

To conduct the study, 452 patients with atraumatic full-thickness shoulder rotator cuff tears provided data via questionnaire on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcome assessments. Physicians also recorded physical examination and imaging data. Patients then began a physical therapy program developed from a systematic review of the literature and returned for evaluation at six and 12 weeks.

At those visits, patients could choose one of three courses: 1. Cured (no formal follow-up scheduled), 2. Improved (continue therapy with scheduled reassessment in six weeks), or 3. No Better (surgery offered). Patients were also contacted by telephone at one and two years to determine whether they had undergone surgery since their last visit and a Wilcoxon-signed rank test with continuity correction was used to compare initial, six-week, and 12-week outcome scores.

The results? Patient-reported outcomes improved significantly at six and 12 weeks and patients elected to undergo surgery less than 25% of the time. The patients who did end up deciding to have surgery generally did so between six and 12 weeks, and few had surgery between three and 24 months.

This study suggests that nonoperative treatment using this physical therapy protocol is indeed effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for two years.

If you have questions about treatment options for your shoulder injury or would like to make an appointment, please contact our office.

Causes and Treatments of Common Shoulder Injuries

shoulder painThe shoulder is a complex joint that facilitates the movement of the arm . Without this crucial joint, the most basic movements of the arm and hand would be impossible.

Think about the mobility that the shoulder affords the arm and hand. Although it is crucial for our daily activities, this movement often comes with a price as we age. Over time the shoulder joint can wear down causing increasing pain.

Due to the complexity of the joint, there are many categories that shoulder injuries fall under:

  1. Fractures
  2. Instability
  3. Arthritis
  4. Soft tissue inflammation and tears

Fractures

Shoulder fractures usually consist of a complete or partial break of the collarbone (clavicle), upper arm bone (humerus), and the shoulder blade (scapula). This type of injury can range from minor to severe depending on how the injury was suffered. Shoulder fractures are accompanied by severe pain, swelling, bruising, and decreased mobility.

The most common causes of these fractures are car accidents, contact sports injuries, and falls. While the treatment of the injury depends on the severity and patient type, the most common treatment is a sling, worn for 8 weeks. However, surgery may be required in more severe cases. In all cases extensive Physical Therapy is needed after healing to regain strength and mobility.

Instability

The shoulder is the most mobile joint in the body, putting it at high risk for instability. This phenomenon occurs when the upper arm bone comes out of the shoulder socket. Once this happens the shoulder may “catch” or become completely dislocated. Instability in younger patients can be a huge problem that creates recurrent issues if the problem is not addressed properly. As the ligaments around the shoulder have been torn during the dislocation, instability can persist if the ligaments do not heal. Recurrent dislocations can occur, causing pain and ultimately arthritis.

Shoulder instability usually happens as a result of a specific sports injury or trauma. There is very little possibly that it will occur without a specific injury. Treatment usually involves the wearing of a sling and extensive physical therapy. However, if the muscles are not strengthened, and dislocation continues, surgical stabilization may be necessary. New minimally invasive arthroscopic shoulder surgery can fix the problem quickly with a shorter recovery period.

Arthritis

The most common type of shoulder arthritis is osteoarthritis. This type of arthritis comes from extreme wear and tear and/or age. At the onset of shoulder arthritis, people try to minimize the pain by using the shoulder less. Although this decreases the pain, immobility for too long leads to tightening of the joint resulting in even more pain.

Osteoarthritis is extremely common, and is often the result of genetics or family history. Sports or work injuries and/or chronic wear and tear are also common causes. Previous shoulder injuries, like rotator cuff tears, and multiple dislocations can cause painful shoulder arthritis as well.

So, how do you relieve this pain? Most effective pain management comes from lifestyle changes, range-of-motion exercises, physical therapy, and rest. Your doctor may also prescribe some pain reduction medications like ibuprofen. Only in the most extreme cases will you be advised to have joint replacement. If you do require joint replacement, make sure to talk to your doctor about minimally invasive shoulder replacement.

Tendon inflammation and tears

Tendon injuries and tears of the shoulder are extremely common. Overuse can easily cause tendonitis or bursitis; both of which inhibit shoulder mobility and cause extreme pain.

Although there are many tendons in the shoulder, the most commonly injured are the rotator cuff tendons and or the biceps tendon. Rotator cuff strains or partial tears may progress to get worse due to aging blood supply and or impingement. Impingement is usually due to bone spurs pinching the tendon during motion.

The best way to prevent an inflamed shoulder Tendon from tearing is rest. Avoiding activity will allow the tendons to heal, reducing the risk of a tear. Anti-inflammatory medications or injections may be prescribed along with rest and physical therapy. However, if these measures do not work, the Tendons can tear. Once this happens, Therapy is less successful and surgery may be advised.

Nobody wants to suffer from shoulder pain. So, if you find yourself suffering from any one of these shoulder injuries come see Dr. Stickney. He will provide you with the best treatment, tailored specifically to your injury and condition. Don’t wait, come see Dr. Stickney and get back to your normal routine faster.

How PRP Affects Soft-Tissue Injuries

intra-articular injectionThe discussion about stem cell injection or platelet-rich plasma (PRP) treatment is becoming a more popular topic by the minute. PRP treatment is being proposed as an alternative to normal orthopedic treatments that tend to be costly for the wallet and for your time. In a previous blog we looked at PRP treatments’ ability to handle orthopedic difficulties like ACL reconstruction, fractures, and osteoarthritis. This time, let’s shift our focus to: how PRP affects soft-tissue injuries.

For the purpose of this analysis we will look at how PRP affects knee meniscal repair, shoulder rotator cuff repair, and tendon healing.

Meniscal Repair

The evidence for how PRP affects meniscal repair is short, concise, and inconclusive. There is only one good study, which we can reference, that gives us any conclusive data about how PRP affects knee meniscus repair. This particular study examined animal models in which scaffolds were used for PRP injection. After 12 weeks it was concluded that PRP augmentation showed no significant difference from the control group in meniscal regeneration/repair. Thus, more studies are needed, perhaps in human subjects, to determine if PRP can aid meniscal repair.

Rotator Cuff Repair

Shoulder r-otator cuff tears are one of the most common injuries that orthopedic surgeons face. For this reason there has been much research focused on the biologics of these types of injuries. These studies are most concerned with the tear location, time to fixation, need for surgery, optimal surgery technique, etc. To see if PRP treatments can aid in the healing process of rotator cuff repair 5 randomized controlled trials (RCT) and 3 nonrandomized trials were completed.

In one of the tests, it was found that patients who received PRP augmentation saw higher retear rates of the rotator cuff. Furthermore, those same patients saw no significant difference in the healing process. Thus, according to this study it seems that PRP augmentation may have detrimental effects to the rotator cuff repair process.

In other similar studies it was also found that PRP use had no significant advantages after rotator cuff repair in relation to pain, motion, strength, or retear rate. However, there was a study in Italy that showed that PRP injections used in conjunction with a thrombin component did have some positive results.

Overall though it has been concluded that there is no clear benefit of PRP use in arthroscopic rotator cuff repair, if it is used alone. In fact, in two cases it proved to be detrimental to the effectiveness of the surgery. More studies are needed to determine the usefulness of PRP injections in rotator cuff repair.

Tendon Healing

Although there has been little positive evidence suggesting use of PRP found in meniscal or rotator cuff repair, there have positive outcomes in relation to tennis elbow and Achilles tendinopathy.

Normal treatment of tennis elbow is a combination of bracing, physical therapy, and steroid injections. In three different studies the steroid injections were substituted for PRP injections. In all three studies the group that received the PRP injection noticed significantly less pain and faster healing time. Thus, it can be concluded that PRP injections can help the healing of tennis elbow.

Achilles tendinosis is another soft-tissue injury that has been treated using PRP injections. Normally this condition is treated nonsurgically with rest, pain medications, physical therapy, bracing, orthotics, and ultrasound. PRP use here aims to improve and speed the healing process. In two studies no significant healing improvement was found when PRPs were used compared to saline injections. One study did show that the use of PRP did slightly improve functional outcomes of Achilles tendinosis, there is not enough statistical evidence to suggest that PRPs are effective in aiding the healing of Achilles tendoinosis. Thus, more research is needed.

Conclusions of PRP use for soft-tissue injuries

Even though PRP treatment is still a new and up-and-coming treatment in the orthopedic world, and it may hold much promise. In relation to meniscal and rotator cuff repair it is extremely evident that much more research is needed. Different combinations of PRP need to be tested for efficacy if there is any hope of this treatment becoming successful for soft-tissue injuries. On the other hand there has been some success in treating tennis elbow and Achilles tendinosis.

Although the measure of success has been small in these areas, it leaves hope that PRP treatment for orthopedic injuries could one day be the norm. Thus, doctors and scientists must push on in their research for the best PRP treatment, backed with proven evidence of success.

5 Facts About Shoulder Injuries

Most people think joint problems are limited to serious athletes or older adults. But when it comes to the shoulder, everyone is at risk.

Between the ages of 18 and 88, almost everyone will experience some kind of shoulder issue, according to Gregory Nicholson, MD, an orthopedic surgeon who specializes in shoulder surgery at Rush University Medical Center.

In fact, shoulders are the most commonly injured joints in the body. The unique and complex anatomy of the shoulder makes it …

The Throwing Arm of a Baseball Pitcher – Understanding Shoulder Pain

Shoulder pain, particularly related to throwing sports such as baseball, involves the rotator cuff. You may have heard a variety of medical terms related to the shoulder, like rotator cuff tendinitis, rotator cuff tear, or impingement syndrome. But what does this mean  to a baseball athlete?

The first piece of good news is tha shoulder pain, like most other Pitcher at Mound, Throwing the Ballsports-related injuries, rarely requires surgery. Now that we are hopeful that surgery will not likely be required, what can we do to alleviate the shoulder pain and prevent it from coming back?

Before discussing treatments for shoulder pain, a basic understanding of the anatomy of the shoulder may be helpful. The shoulder is a complex joint. There are three bones and two joints that contribute to shoulder function– the humerus, clavicle, and scapula are the bones. The ball and socket joint of the shoulder is between the humerus and the scapula. The acromial clavicular joint between the scapula and clavicle moves with forward elevation of the arm and helps stabilize the shoulder on the chest wall. The shoulder is the most mobile joint in the body and because of this it is easily injured.

Causes of Rotator Cuff Injuries

The shoulder joint is often injured in the throwing sports, such as baseball, because it has a greater range of movement than any other joint in the body. Shoulder muscles and ligaments bare a tremendous amount of stress throughout the throwing motion.

When you raise your arm up above your head, as occurs during the cocking and acceleration phases of the pitching motion, the rotator cuff muscles can be pinched under the acromion, causing irritation and occasionally sharp pain felt on the front or top of the shoulder. This situation is referred to as “shoulder impingement’ or “impingement syndrome”.

Deceleration

 A good throwing technique requires the athlete to use his body weight and the large muscle groups of the legs, back and trunk to generate kinetic energy across the shoulder in the direction of the thrown object. After the ball is released, the retained energy in the throwing arm needs to be dissipated back to the large muscles which then absorb it. Stated more simply, after a ball is thrown, the arm must decelerate. The large muscles of the back and trunk, as well as the triceps and the rotator cuff all assist in deceleration of the arm. A tremendous amount of stress can be placed on the rotator cuff muscles as they assist in decelerating the arm after the ball is released. This is particularly true in pitchers who don’t follow through all the way. By not following through, deceleration must occur abruptly, increasing the amount of stress that is placed on the smaller and more easily injured rotator cuff muscles.

Biomechanics

As stated above, when a pitcher has poor biomechanics, undue stress can be placed on the soft tissue structures of the shoulder. Different biomechanical flaws place stress on different structures. Volumes have been written on the subject. What is important to remember here is that pitchers with poor throwing biomechanics place undue stress on the smaller rotator cuff muscles, compared to the stronger muscles of the back and trunk.  Ensuring that an athlete learns proper throwing technique is a worthy investment in the health of their arm.

 Overuse 

Overuse is the most common source of throwing related injuries. Most importantly, it is avoidable. Paying close attention to pitch counts and giving athletes ample rest is the best way to prevent overuse injuries. It is important that athletes are allowed to come out of a game at the first sign of shoulder discomfort or soreness, even if it is not convenient to the goal of winning the game that day.

Treatment and Prevention

Reduce Inflammation – Using the RICE method: 1) Rest; 2) Ice; 3) Compression; and 4) Elevation

Myofascial Release – When muscle tissue is injured, scar is formed. Scar formation (also called myofascial adhesion) is the body’s way of patching an injured area. The problem with scar is that it is tough and fibrous, whereas healthy muscle is supple and elastic, like a rubber band. Myofascial Release Technique is used to break up scar formation and restore the muscle’s elasticity, or rubberband-like characteristics. Once the rotator cuff muscles are painfree and myofascial adhesions are broken, therapeutic exercises are essential to a complete recovery. It should also be noted that myofascial release technique can increase throwing velocity by optimizing the elasticity of the throwing muscles.

Stretching and Strengthening Exercise – Stretching and strengthening of the rotator cuff is crucial to completing shoulder rehab and remaining pain free. A few simple rotator cuff exercises will strengthen the muscles, resulting in injury resistance and optimal performance. You’ll notice that college and major league pitchers perform rotator cuff exercises on a regular basis, even when they are not injured. This speaks volumes to the importance of a healthy rotator cuff in pitchers, as well as other athletes whose sport involves repetitive stress on the shoulder.

If you are shoulder pain due to a sports injury, please call me at 425-823-400 or email me at ProOrthoAppointment@proliancesurgeons.com to schedule an appointment.

Common Weightlifting Injuries

Weight training is a sport as well as part of someone’s exercise regimen.  Experienced weightlifters rarely suffer serious injuries but newcomers to the sport or exercise are more prone to musculoskeletal injuries.

Distal biceps rupture:

This is a rupture of the biceps tendon that attaches the biceps muscle in the arm to a bone of the upper forearm. A weightlifter can rupture this tendon at the elbow with a sudden force that extends the elbow while trying to contract the biceps. Performing a biceps curl and then losing control of the weight is an example. Surgery to reattach the tendon is usually needed. Less traumatic and sometimes requiring surgical repair, a biceps tendon tear can also occur. Choosing weights one can reasonably lift and fully control can help prevent a distal biceps rupture. 

Labral tear:

The labrum is a cartilage bumper in the shoulder that surrounds the glenoid (socket). With repetitive compression of the labrum or possibly an acute motion that injures the shoulder, the weightlifter can feel discomfort or a clicking sensation deep within the shoulder. An orthopedic surgeon can perform a physical exam and tests that suggest a labral tear. An MRI with contrast injected (MR arthrogram) can demonstrate a tear. Surgery is often required to treat a shoulder labral tear if it limits activity. Proper technique and having shoulder pain evaluated early if it is not improving can be helpful.

Shoulder impingement:

This is more of a cause of chronic shoulder pain in a weightlifter rather than an acute injury. Avoiding exercises that cause pain can help the problem. Working with a physical therapist to improve shoulder mechanics and strengthen the muscles around the shoulder can often speed recovery. Seeing an orthopedic surgeon or a physical therapist when this problem develops and starting a treatment program can often accelerate return to overhead lifting.

Lower back muscle strain:

A strain of the muscles of the lumbar spine can occur from using improper technique with exercises or picking up or putting down weights awkwardly. Fortunately most don’t require more aggressive treatment than rest and activity modification. Proper lifting technique is key. 

Quadriceps or hamstring muscle strain:

Acute strains of the quadriceps and hamstring muscles from squats, leg presses, lunges and other lower extremity exercises can occur. Most heal without surgery and require only rest and short-term exercise modification. Beyond strains, hamstring tears can happen, which is why proper exercise techniques and choosing an appropriate amount of weight can help prevent injuries.

Patellar or quadriceps tendonitis:

These are also more chronic issues with the tendons around the knee than acute injuries. Pain in the tendons above or below the kneecap with lower extremity exercises can develop and worsen over time. Often short-term avoidance of exercises that reproduce the pain, anti-inflammatory medication, and ice can resolve the problem.

In addition to the above mishaps are knee injuries, including  knee bursitis, knee tendinitis, and knee muscle tears. Many of the injuries listed here can be prevented by using proper technique. Often simply rest and short-term activity modification can prevent a minor pain from turning into a more serious injury.

If any musculoskeletal pain continues to limit your ability to work out the way you want, consider visiting Dr. Stickney to learn and understand possible treatments by calling 425-823-400 to schedule an appointment or email him at ProOrthoAppointment@proliancesurgeons.com.