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Shoulder Articles About Arthroscopic Shoulder Surgery Performed by Dr. Stetson:

Shoulder Anatomy

The shoulder is a mobile joint that allows the arm to move in many different directions. It is a ball and socket joint but, unlike the hip joint, which has a deep socket for the ball of the hip to fit into, the shoulder socket is very shallow. It has been compared to a “golf ball” on a tee.” The surrounding muscles and ligaments provide stability to keep the shoulder in the socket and allows for a removable range of motion.

The glenoid is the socket of the shoulder joint. It is made of bone and its surface has a smooth layer, called articular cartilage.

The humeral head, or the head of the humerus, fits into the glenoid. The humeral head also has articular cartilage. The glenoid and the humeral head make up the shoulder joint, also know as the glenohumeral joint.

The labrum is a piece of fibrous tissue made of a different sort of cartilage, called fibrocartilage, which surrounds the glenoid. It forms a rim like structure which aid in stabilizing the joint and provides an attachment for the ligament of the shoulder. The labrum can tear which can lead to the shoulder being unstable, or dislocating out of the socket.

The acromion is a bone located on the top of the shoulder joint. It can have a hook of bone in front which can pinch the rotator cuff and the bursa leading to impingement or bursitis.

The bursa is a fluid-filled sac that helps cushion the rotator cuff so the muscles and tendons can move smoothly. The bursa can become inflamed and lead to bursitis (Impingement).

The rotator cuff muscles surround the shoulder joint and act to move and stabilize it. There are four different  rotator cuff muscles. They attach are four different rotator cuff muscles. They attach to the humeral head by way of tendons. When these tendons get irritated, it is tendinitis. When these tendons actually tear, either partially or completely, from the humeral head, this is what is known as the rotator cuff tear. Unfortunately, complete rotator cuff tears do not heal and must be reattached surgically.

The ligaments of the shoulder are thickenings of the shoulder capsule or sac that surrounds the shoulder joint. The ligaments are cord-like and help to stabilize the shoulder joint and keep the ball within the socket.

The clavicle, or collarbone, is the main bone that connects the shoulder to the rest of the body. The acromioclavicular joint is made up of where the acromion meets the clavicle. It is stabilized by ligaments. When these ligaments become damaged, sprained, or torn, it is called shoulder separation.

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Shoulder Arthroscopy

Figure 1 –An Arthroscope is small, pencil sized instrument which has specialized fiber-optics with a light at the end.

An Arthroscope is small, pencil sized instrument which has specialized fiber-optics with a light at the end. These fibers beam a light into your joint and this projects a picture back to a television monitor in front of your surgeon. This allows the surgeon to view inside of your shoulder to see what is damaged.

The Arthroscope is placed into your shoulder joint through a small, quarter inch incision called a “portal.” One or two other small incisions or portals are also made which allows your surgeon to insert other instruments inside of your shoulder to see what is damaged.

The Arthroscope is placed into your shoulder going through a small, quarter inch incision called a “portal.” One or two other small incisions or portals are also made which allows your surgeon to insert other instruments inside of your shoulder. These specialized instruments can help remove damaged tissue., smooth rough edges, remove bone spurs, and even repair ligaments or tendons such as the rotator cuff.

These small incisions means less pain after surgery and quicker recovery as compared to open surgery. Almost all patients are allowed to go home the same day of surgery.

Dr. Stetson is at the forefront of treating complex shoulder injuries with the latest arthroscopic techniques.

What are the advantages of shoulder arthroscopy?

Using advanced surgical techniques we can now treat many rotator cuff injuries using the arthroscope. Many rotator cuff injuries can now be fixed using advanced arthroscopic techniques, which means smaller incisions, less pain after surgery, and faster rehabilitation.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

William B. Stetson, MD
Associate Clinical Professor
University of Southern California Keck School of Medicine
Department of Orthopaedic Surgery

Common Shoulder Problems

What makes up the shoulder joint?

The shoulder is really made up of several joints, muscles and tendons and allows a wide range of motion of the arm. However, because of this mobility it may lead to increasing problems with the soft tissues surrounding the shoulder resulting in pain. Pain may be present only when the shoulder is moved or brought above your head, or may be present all the time. If the pain persists, it may require medical diagnosis and treatment.

Dr. Stetson is an expert in diagnosing and treating complex shoulder problems. From the professional athlete to the weekend warrior, and to the injured worker, our team of physicians and physical therapists work together to get you back to your activities as soon as possible.

What causes shoulder pain?

Most shoulder problems involve not the bones but the muscles, ligaments and tendons which surround the shoulder joint. The majority of shoulder pain is caused by tendinitis or bursitis, instability or an unstable shoulder joint, a direct injury to the shoulder such as a fall, or arthritis.

TENDINITIS: The tendons of the shoulder help connect the muscles to the bone. When they get inflamed this is known as tendinitis. The majority of tendinitis is a result of the wear and tear which takes place over many years and this is known as chronic tendinitis. Acute tendinitis comes on quickly after some sort of overuse such as throwing a baseball for the first time in a while or some other sports or work-related activity.

BURSITIS: When the tendons become inflamed or irritated tendinitis develops. The bursa, which is a fluid-filled sac, lies on top of the tendons and also often becomes inflamed. This is known as bursitis. Just like tendinitis, bursitis may come on quickly or slowly. Pain may develop in the front or side part of the shoulder.

Sometimes it goes away with a little rest, sometimes it doesn’t.

Patients often wait too long to seek treatment. If your shoulder pain isn’t improving, it may be time to make an appointment to see one of our shoulder experts.

ROTATOR CUFF INJURIES: The rotator cuff is actually made of four small muscles which surround the shoulder joint. The splitting and tearing of these muscles and tendons may result from an acute injury such as a fall or from the wear and tear of the years. Patients often complain of pain doing things over their head or pain at night. Rotator cuff injuries are very common and are best treated early before small tears become large tears.

FROZEN SHOULDER: The shoulder may become so painful that patients don’t want to move it at all. The joint may stiffen as a result leading to a condition, “frozen shoulder.” Early, aggressive therapy is essential. Dr. Stetson works closely with our therapists in treating this problem and getting the shoulder moving again without pain.

UNSTABLE SHOULDER/ INSTABILITY: The shoulder joint is like a golf ball on a tee. The socket, or tee, is very shallow which allows the ball, or humeral head, to move around freely. The shoulder joint is dependent on all the ligaments around it for stability or keeping the ball in the socket. Instability or an unstable shoulder can result when an injury occurs, stretching or tearing the ligaments. The shoulder can partially or completely slip out of the socket or dislocate causing severe pain. When it partially slips out, this is known as subluxation and may occur in athletes such as baseball pitchers or volleyball players. Our team of physical therapists are experts in treating young and older athletes with unstable shoulders. With a carefully monitored, physician directed rehabilitation program, we are able to get most athletes back to competition quickly and without surgery. When surgery is necessary, our physicians use the latest arthroscopic techniques which help speed up your recovery.

ARTHRITIS: Shoulder pain can also be caused by arthritis. Although there are many types of Arthritis, it generally involves the wear and tear of the joint. This typically causes swelling, pain and stiffness. It may be caused by some sort of injury or doing repetitive activities at work or at home.

HOW IS MY SHOULDER PROBLEM DIAGNOSED?

Before any treatment can be recommended, it is essential to determine the source of the problem.

The first step is a detailed medical history determining how and when the pain started. Many shoulder conditions are aggravated by specific activities so a detailed questionnaire is a valuable tool in finding the source of your pain.

A careful physical examination noting any swelling, weakness, tenderness is then done observing the range of shoulder motion – how far and in which direction you can move your arm.

X-rays may also be required to closely look at bones and joints of your shoulder. Magnetic resonance imaging, an MRI, is also a valuable tool which allows us to see the muscles, tendons, and ligaments of the shoulder without using radiation.

TREATMENT: Early treatment of shoulder problems is essentially to prevent long term complications.

Dr. Stetson is an expert in the treatment of complex shoulder problems. This involves an aggressive physical therapy program under the watchful eye of your physician in order to relieve the pain and improve the strength in your shoulder.

Anti-inflammatory medications are often prescribed to help relieve the pain. In addition, cortisone injections may also be used to help relieve the pain when regular oral pain medications don’t do the job.

If all else fails, surgery may be required to resolve your shoulder problem. With the advent of shoulder arthroscopy, many shoulder problems can be treated using this advanced technique.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

Rotator Cuff Injuries

Dr. Stetson explains a Rotator Cuff Repair on “The Doctors” TV show. Click here to watch the video.

What is the rotator cuff?

The rotator cuff comprises four separate muscles that surround the top of the shoulder. These muscles stabilize the ball of the shoulder joint to keep it in the socket. The four muscles include the supraspinatus muscle, the infraspinatus muscle, the subscapularis muscle, and the teres minor muscle. The supraspinatus is the most commonly injured of the four muscles.

How is the rotator cuff usually injured?

In people under the age of 25, rotator cuff injury is usually caused by overuse or by activities that require repetitive shoulder motion, such as tennis, swimming, or baseball, and the pain generally occurs during the overhead portion of the activity. This injury, referred to as tendinitis, is common in young people and usually results from strain of the rotator cuff muscles.

In people between the ages of 25 and 45 years, rotator cuff problems usually occur from chronic overuse. These patients usually

have a history of persistent pain with any overhead activities. They may have “popping” in the shoulder and also may complain of pain, which continues even during rest and may wake them up from sleep. These symptoms may appear if someone has begun a new exercise or a new workout routine using the shoulder muscles. Weakness also is common in this age group.

In people from 45 to 65 years of age, shoulder pain may occur secondary to a structural problem. A small hook of bone can form and rub the top of the rotator cuff muscles, causing pain and inflammation of the rotator cuff. This is commonly referred to as

bursitis. If the shoulder movement is limited, the rotator cuff and also the biceps tendon may have been worn away by the bone spur. A common complaint is chronic pain and weakness, which is exacerbated by lifting anything. Theses people report a noticeable increase in pain at night. Some locking or catching in the shoulder also may occur.

In people over 65 years, rotator cuff tears are very common. Depending on a person’s activity level, the symptoms may be less or more severe than those reported by someone in a younger age group. The pain can be debilitating, and if not treated properly, may lead to degenerative arthritis of the shoulder.

How is a rotator cuff tear diagnosed?

A clinical exam will identify the location of pain and tenderness during range of motion of the shoulder. People often have pain raising their shoulder actively above their head. Routine x-rays will not diagnoses a rotator cuff tear, but they will show bony overhang that catches on the rotator cuff. Sometimes a physical exam will not identify a rotator cuff problem and further diagnostic tests, such as an MRI, are needed to fully evaluate the rotator cuff muscles. Other problems such as biceps tendinitis or ganglions (fluid-filled cysts) in the shoulder can mimic rotator cuff tears. MRI can help to evaluate the cause of shoulder pain.

How is a torn rotator cuff treated?

Nonsteroidal anti-inflammatory medicines and physical therapy are necessary when a rotator cuff muscle is inflamed. The physical therapy regimen may include muscle strengthening and ultrasound treatment. Applying ice directly to the area that is most painful also can help to reduce swelling and relieve pain. A steroid injection can also relieve the pain and inflammation. This especially provides relief of tendinitis of the rotator cuff. However, when the rotator cuff is partially or completely torn, physical therapy and muscle strengthening is not always helpful. In these cases arthroscopic surgery is usually necessary to shave the undersurface of the bone that catches on the rotator cuff. Anything on the rotator cuff muscle that may be impinging on the undersurface of the bone can be removed at the same time. If the muscle is completely torn, then it is necessary to reattach the rotator cuff to bone. This can be done arthroscopically or through a small skin incision approximately two to three inches in length. The muscle is reattached to bone to relieve pain and improve shoulder function. Using advanced arthroscopic techniques, recovery is much faster, and less painful then with traditional open shoulder surgery.

How soon will a rotator cuff muscle heal?

If it is necessary to repair the rotator cuff muscle, it may take six weeks to two months for the tendon and muscles to completely heal. People who engage in activities that require overhead movement may need three to four months to heal, depending on the extent of the rotator cuff tear. If the muscle is only partially torn and is repaired at the time of surgery, recovery is much faster.

What is subacromial decompression?

Sometimes a small hook of bone can catch on the rotator cuff and cause pain and inflammation of the rotator cuff muscles. This is commonly referred to as bursitis and it will sometimes respond to an injection of steroids and local painkillers. However, if this treatment does not relieve the pain, it may be necessary to perform arthroscopic surgery to shave the undersurface of the bone. This is done through three small skin incisions. Recovery time from this type of surgery is very fast and people often are able to return to their activities by six weeks after the operation.

In addition, our surgeons also use an automatic pain pump after surgery, which gives pain medicine directly to the incision site for 48 hours after surgery. This helps your recovery after surgery to be comfortable and much less painful.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

Injuries to the AC Joint in the Shoulder

What is the AC joint in the shoulder?

The top of the wing bone or scapula is the acromion. The joint formed where the acromion connects to the collar bone or clavicle is the AC joint. Usually there is a protuberance bump in this area, which can be quite large in many people. This joint, like most joints in the body, has a cartilage disk or meniscus inside and the ends of the bones are covered with cartilage. The joint is held together by a capsule, and the clavicle is held in the proper position by two heavy ligaments called coracoclavicular ligaments.

How is the AC joint usually injured?

The AC joint injured most often when one falls directly on the point of the shoulder. The trauma will separate the acromion away from the clavicle, causing a sprain or dislocation of the AC joint. In a mild injury, the ligaments which support the AC joint are simply stretched (Grade I), but with more severe injury, the ligaments can partially tear (Grade II) , or completely tear (Grade III). In the most severe injury, the end of the clavicle protrudes beneath the skin and is visible as a prominent bump.

How is an AC joint separation diagnosed?

Most often the clinical exam will demonstrate tenderness or bruising around the top of the shoulder near the AC joint, and the suspected diagnosis can be confirmed with an x-ray that will compare the injured side with the healthy joint.

What is the proper treatment for a sprained AC joint?

When a joint is first sprained conservative treatment is certainly the best. Applying ice directly to the point of the shoulder is helpful to inhibit swelling. The arm can be supported with a sling which also relieves some of the weight from the shoulder. Gentle motion of the arm is allowed to prevent stiffness and exercise putty is very helpful to improve function of the elbow, wrist, and hand, but any attempts at vigorous shoulder mobilization early on will probably lead to more swelling and pain.

How long des it take for a shoulder separation to heal?

Depending on how severe the injury is, it may heal adequately in two to three weeks. In severe cases, the shoulder may not heal without surgery.

When and why is surgery necessary for AC joint separations?

Usually surgery is reserved for those cases of residual pain on unacceptable deformity of the joint after several months of conservative treatment. The pain can occur with direct pressure on the joint, such as with straps from underwear or work clothing. Sometimes there will be catching, clicking, or pain with overhead activities, such as lifting, throwing, or reaching. Finally, in some people with very think skin and very little muscular and soft tissue padding above their shoulders, the prominent clavicle after the separation may be considered unattractive, since the shoulder can appear to be unbalanced.

Are there other causes of AC joint pain and disability?

Arthritis can occur as an isolated event in the AC joint, causing stiffness, aching, and some times swelling. Another condition, called distal clavicle osteolysis (DCO), gives a similar picture usually in young people who lift heavy weights. This is called “weightlifter’s shoulder.”

What type of surgery can repair AC joint problems?

The simplest type of surgery for AC joint injury involves resection for removal of the end of the clavicle using arthroscopic (mini-surgical) techniques (called a Mumford procedure). If the joint becomes painful because of DCO or arthritis, or the separation is only minor, this technique can be very satisfactory. When the joint is severely displaced, than a more complex procedure is needed to restore the position of the clavicle. This operation, called a Weaver-Dunn procedure, usually is done by making a two-inch incision over the joint, removing the end of the clavicle, and transferring the ligament from the underside of the acromion into the cut end of the clavicle to replace the ligaments torn during dislocation.

What is the postoperative and rehabilitation?

Postoperatively, treatment depends on the type of surgery performed. Usually, when the Mumford procedure is performed using an arthroscopic technique, the arm can be treated with a sling. Bathing is allowed after three days, and elbow, wrist and hand exercises are begun immediately. Lifting is limited for three weeks, but following that, progressive exercise and motion activities proceed as the symptoms allow.

When a Weaver-Dunn procedure (rebuilding of torn ligaments) is needed, approximately two or three weeks is added to the immobilization time before motion exercises are begun. This time allows the ligament to heal. Otherwise, the exercise program is the same as that for the Mumford procedure.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

What is Adhesive Capsulitis?

Adhesive capsulitis is the technical term for “frozen shoulder.: The shoulder joint is supported by ligaments which connect the shoulder bones together and keep them properly aligned during motion. Normally the ligaments are flexible enough to permit full movement of the shoulder. When adhesive capsulitis occurs, the ligaments develop an inflammatory process, causing scar tissue to infiltrate and form very restricting adhesions. This “freezing” of the joint severely decreases the shoulder’s normal range of motion and causes considerable pain during motion.

Who is most at risk?

Women 40 years of age and older are most likely to develop frozen shoulder. Some medical conditions, such as diabetes, cardiovascular disease, or breast surgery, can be associated with frozen shoulder, but the condition can and often does occur in any healthy individual, man or woman, without any predisposing medical condition or trauma.

How do the symptoms develop?

Adhesive capsulitis progresses through three phases. The symptoms of the first phase, or “freezing phase” are the onset of generalized pain about the shoulder which increases with movement and results in loss of motion. Because of the pain resulting from the inflammation, the patient elects to protect the shoulder by not moving it, thereby setting the stage for the scar tissue to infiltrate and bind the shoulder even tighter.

The second phase or “frozen phase:, is distinguished by localized pain and tenderness about the humeral head (ball of the shoulder), and discomfort that seems to worsen at night and often interferes with sleep. During this phase, the inflammation is slowly subsiding and the scar tissue is maturing.

The final phase, or “thawing phase,” embodies a less painful shoulder but with significantly the scar tissue may begin to loosen and shoulder motion can slowly return.

How is adhesive capsulitis diagnosed?

The diagnosis of frozen shoulder is usually made by an orthopaedic surgeon. The symptoms of shoulder pain are often confused with such things as calcific bursitis, rotator cuff tears, arthritis, or tendinitis. Although these more serious conditions are thought to sometimes precede adhesive capsulitis, the condition usually is an isolated event. When the surgeon notices a decrease in shoulder motion, particularly in flexion and rotation, the diagnosis is suspect. When x rays, an MRI, and a physical exam rule out other causes of pain, then the diagnosis is confirmed.

How is adhesive capsulitis treated?

The treatment of adhesive capsulitis depends on the stage and the severity of the condition. Often, in the early stages, oral anti-inflammatory medications help to decrease the joint inflammatory reaction, and may thereby decrease the scar tissue formation by allowing more pain-free range of motion. In addition, physical therapy, including phonophoresis (sometimes with corticosteroids), ultrasound, and hot and cold treatments, can be helpful. A physical therapist who is familiar with this condition is also very helpful in performing active-assisted and passive gentle manipulative range of motion activities. Our physical therapists are experts in treating “frozen shoulder” A home exercise program, using an overhead pulley and stretching activities with a cane or wand, must be included in the therapy program.

Pain or analgesic medicines are often necessary to help with the discomfort, particularly during the “frozen phase.” Non-narcotic medications are preferable such as Vioxx or Celebrex (New non-steroid anti-inflammatories)

Surgery for adhesive capsulitis is limited to manipulation under anesthesia. In our practice, this is usually performed at outpatient surgery. With the patient asleep, the physician attempts to manipulate the shoulder through a full range of motion to stretch the tight scar tissue surrounding the joint. It is sometimes necessary to perform an arthroscopic exam or an open surgical procedure; to release additional adhesion in more severe cases, this may be needed. After manipulation the patient must continue physical therapy and home exercises. On rare occasions, two or sometimes three manipulations are needed since the adhesion may reform if the inflammatory process remains active.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

Calcium Deposits in the Shoulder

Here is an example of a calcium deposit in a 45 year old female with increasing right shoulder pain. See the image below for an arthroscopic view of this calcium deposit in the rotator cuff.

Calcium deposits around the shoulder are fairly common. They usually do not cause problems, but if they increase in size or become inflamed, they can be very painful. This collection of questions and answers is intended to explain this common shoulder problem and describe the methods we recommend for treatment in different situations.

Why do calcium deposits form around the shoulder?

Most calcium deposits have no known cause. People often believe the deposits occur from too much calcium in their diet, so they ask if they should reduce their calcium intake. This should never be used as a from of treatment, since a normal balanced diet with a calcium supplement of up to 1000mg a day is healthy; particularly for anyone past 55 years of age, and for post-menopausal women.

 

 

 

How are calcium deposits diagnosed?

Calcium deposits are usually diagnosed with a routine x-ray. In some patients, they are just an incidental finding and cause no pain or symptoms. However, if the calcium deposit becomes too large or starts to grow, it can cause severe pain as it starts to erode the rotator cuff.

Who usually develops calcium deposits?

Calcium deposits develop most frequently in women between 35 and 65 years of age, but they also develop in men.

Here is the arthroscopic view of the calcium deposit in the shoulder located in the rotator cuff, the most common location for it to occur. It can erode the rotator cuff and cause pain and destruction of the rotator cuff tendon.Many calcium deposits are present for years without causing pain. Only when they are large enough to be pinched between the bones when the shoulder is elevated do they cause pain. Smaller deposits may cause pain if they become inflamed, especially when the calcium salts leak from the deposit into the sensitive bursal tissues of the joint lining.

Here is the arthroscopic view of the calcium deposit in the shoulder located in the rotator cuff, the most common location for it to occur. It can erode the rotator cuff and cause pain and destruction of the rotator cuff tendon.Many calcium deposits are present for years without causing pain. Only when they are large enough to be pinched between the bones when the shoulder is elevated do they cause pain. Smaller deposits may cause pain if they become inflamed, especially when the calcium salts leak from the deposit into the sensitive bursal tissues of the joint lining.

Will calcium deposit damage my shoulder?

Some calcium deposits can cause erosion by destroying a portion of the rotator cuff tendon. However most calcium deposits remain on the outside of the rotator cuff tendon the bursa (the structures that hold the the joint fluid) and only cause problems because of the pain caused when they catch during shoulder movement.

Is the calcium deposit hard like a rock?

In the early part of formation, most calcium deposits are very soft like toothpaste, but when they have been present for a long period of time, they dry and become chalk-like, sometimes even turning to bone.

Here is an example of a calcium deposit which is in its early stages and is very soft.

 

 

 

 

 

Here is an example of a calcium deposit which is in its early stages and is very soft.

What is the best treatment for a calcium deposit depends on what sort of symptoms it is causing. When the calcium deposit becomes inflamed, either because it ruptures and leaks calcium salts into the bursa, or because it pinches the bursa or rotator cuff, the pain can be quite severe. The acute inflammation can be treated with ice packs over the area and rest in a sling, but oral anti-inflammatory medications are also helpful. A cortisone injection directly into the area of the calcium deposit may provide relief with a few hours, but without it, severe pain may last for several days.

Should calcium deposits be removed?

If someone has two or three episodes of recurrent pain and inflammation in the shoulder, or if the calcium deposit appears on x ray to be enlarging, then arthroscopic surgery to remove it should be considered.

 

 

The tip of the needle points to the calcium deposit.

Stages of calcium deposit in shoulder

What is involved in arthroscopic surgery to remove calcium deposits?

The procedure is done as outpatient surgery under general anesthesia. The operation is painless, and only a mild aching sensation is felt for a few days after the operation while the skin puncture sites heal. If the calcium has eroded in a hole in the rotator cuff, then it is necessary to remove a portion of the overhanging bone which will cause a little more discomfort for a few days.

 

 

 

 

Here is an x-ray taken after the arthroscopic surgical procedure. The calcium deposit has been removed and the rotator cuff has been repaired. There will sometimes be some small spots of calcium that are left and seen on the x-ray which will cause no further problems. The most important thing is to decompress the calcium deposit to keep it from eroding the rotator cuff tendon.

Will calcification return once the deposits have been removed?

We have never seen calcification return in the same shoulder.

Will calcification cause any permanent damage?

Yes. A long-term calcification may cause pressure on the rotator cuff tendon which may damage portions of the tendon permanently.

To see more information about the shoulder, including video animations of shoulder anatomy and other shoulder injuries and ways to treat them, please click here.

SLAP Tear of the Shoulder

What is a SLAP tear?

The term SLAP tear refers to a tear of the superior labrum of the shoulder. The labrum is a piece of fibrous tissue made of cartilage, called fibrocartilage, which surrounds the glenoid or the socket of the shoulder. It forms a rim like structure which aids in stabilizing the shoulder joint and provides an attachment for the ligaments of the shoulder. The biceps tendon attaches inside the shoulder joint at the superior labrum or at the top of the shoulder joint. Tears of the superior labrum are called SLAP Tears and can cause shoulder pain mimicking other shoulder problems. These are often difficult to diagnose and can often times be only seen at the time of arthroscopic surgery. The term SLAP was coined by Dr. Steven Snyder of the Southern California Orthopedic Institute where Dr. Stetson did his fellowship. See figure 1 for an example of a SLAP tear.

What causes a SLAP tear?

A SLAP tear can be caused by many different ways. The most common cause is a fall or some other sort of injury to the shoulder. Some patients fall landing directly on their shoulder or others fall on their outstretched hand. Another cause of SLAP tears is repetitive overhead activities seen in tennis players, baseball players, volleyball players or other overhead athletes. Some patients can recall a specific injury while others cannot.

What is the most common complaint?

The most common complaint is pain. In addition, over half the patients with SLAP tears will also complain of painful clicking and popping. SLAP tears are often seen with in combination with other shoulder problems which makes it difficult to diagnose..

How is a SLAP tear diagnosed?

With any shoulder problem, the first step in diagnosing a SLAP tear is to get a complete history and physical examination from a qualified shoulder surgeon. X-rays are also taken and if the symptoms warrant, an MRI is also done. A regular MRI may not show a SLAP tear and so often times an MRI with a dye injected into the shoulder, a so called MR arthrogram, is ordered. This is able to detect a SLAP tear better than just a normal MRI.

How is a SLAP tear treated?

SLAP tears are difficult to diagnose and are often seen with other shoulder problems such as bursitis and rotator cuff tears. Although bursitis and even rotator cuff tendonitis often responds to physical therapy and a cortisone injection, SLAP tears do not. They typically need to be repaired with surgery. This can be done using advanced arthroscopic techniques requiring only two or three small incisions, each less than a half inch in size. It is done as an out-patient surgery, meaning you go home the same day. It does require physical therapy for about six weeks after the surgery and most patients are able to return to their activities about three months following the surgery.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

William B. Stetson, MD
Associate Clinical Professor
University of Southern California Keck School of Medicine
Department of Orthopaedic Surgery

Additional Information about injury and treatment procedures:

What is MRI and Why Did My Doctor Order It?

An MRI, or magnetic resonance imaging study, allows an inside look into your knee or shoulder.

Here at Stetson Powell we have our own MRI Scanner in our office which allows our patients to have their MRI’s done and then often times seeing their doctor right away for an immediate diagnosis. Our MRI scans are also read by a team of musculoskeletal radiologists lead by Dr. Gregory Applegate.

An MRI is not an x-ray and so does not use radiation but rather uses a special magnet imaging system to see what x-rays cannot show us. It is the best test we have to determine what if anything is wrong with your knee or shoulder. Using these test results will allow us to make a better diagnosis and together we will make a plan to return you to full health and vitality.

If you are claustrophobic, an open MRI can be done but does not give us nearly the same detail as a regular or closed MRI. The size of the magnet used in an MRI determines the quality of the pictures and the detail which can be seen. A regular MRI is five times stronger than an open MRI and so whenever possible, we recommend a regular MRI.

If you are having a shoulder MRI, we sometimes use a special technique of introducing a special dye into your shoulder before the procedure. This gives us a much more detailed picture of your shoulder and allows us to make a correct diagnosis of your shoulder condition. It does require a small injection of local anesthetic into the shoulder joint followed by a small amount of dye. This is done by qualified radiologists using special equipment.

I recently did a research project on this technique which has been presented to orthopaedic surgeons here in the United States and also internationally. It was recently published in the Journal of Bone and Joint Surgery (December, 2005, volume 87-A) and the article is here for your interest (618 K PDF file). This is the premier journal of orthopaedic surgery and I am honored to have my research accepted by such a prestigious journal.

Golfer’s Elbow (Medial Epicondylitis)

Golf is a great game and is a good outdoor fitness activity for everyone. However, overuse injuries to the elbow are very common and can put a quick stop to anyone’s game.

The most common problem afflicting golfer’s is “golfer’s elbow” which is a tendonitis of the inside, or medial, part of the elbow. I see this most commonly in player’s who do not warm up properly or play too much their first time out on the links after a long hiatus.

As seen on the right, the tendons on the palm of the hand all attach up at the elbow on the inside or medial part of the elbow. If you are right handed, it most commonly afflicts your right elbow.

This picture along with other useful information about common injuries can be found at the American Academy of Orthopaedic Surgeons website at www.aaos.org or www.orthoinfo.org with more information concerning all types of orthopaedic injuries.

This tendonitis of the elbow can be very painful and can cause pain to radiate down the forearm to the hand. It can also cause a weakness of your grip and make it difficult to hold your club. It can also be associated with entrapment of the nerve at the elbow, called cubital tunnel syndrome. This causes numbness and tingling in the small and ring finger of the hand and can eventually lead to permanent nerve damage if not treated properly. This can also put quite a damper on your golf swing so it is important not to ignore it and to seek advice from a sports medicine physician. Early treatment is the best way to avoid long term problems.

 

 

 

Here are some simple tips to avoid getting golfer’s elbow:

1) Regularly do stretches of the forearm muscles to promote flexibility of the muscles and tendons of the forearm and hand as seen at left. By keeping the elbow straight, stretch the wrist both directions to work the forearm muscles.

2) Squeeze a tennis ball or some other rubber ball for at least five minutes a day. This can done while driving home from a stressful day at the office or even at work while on the telephone.

3) Do wrist curls using a very light weight and then do reverse curls of the wrist, all with the elbow straight to work the forearm muscles.

4) Always stretch before and after playing. If the elbow is sore after playing, ice the area for at least 15 minutes after playing.

5) A brace worn around the forearm while playing can also help reduce the strain around the elbow and helps give your elbow a break.

If your elbow pain does not go away, it may be time to seek medical attention from a qualified sportsmedicine physician as most of these injuries can be treated without surgery. At Stetson Powell Orthopedics and Sports Medicine, we commonly see and treat these injuries and get our patients and golfer’s back on the course.

For more helpful hints on how to avoid golfing injuries, tune in every Sunday morning on ESPN radio 710 am at 6:00 in the morning for the “Tee It Up Show” golf program. Dr. Stetson has appeared regularly on this show as has Dr. Lee showing helpful hints on how to treat golfer’s elbow and other injuries common with golfers.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

William B. Stetson, MD
Associate Clinical Professor
University of Southern California Keck School of Medicine
Department of Orthopaedic Surgery

Tennis Elbow (Lateral Epicondylitis)

Overuse injuries to the elbow are very common and can put a quick stop to anyone’s activity.

The most common problem afflicting tennis players is lateral epicondylitis or “tennis elbow,” which is a tendonitis of the outside part of the elbow. We see this most commonly in players who do not warm up properly or play too much their first time out on the court after a long hiatus.

The tendons on the top of the hand all attach up at the elbow on the outside or lateral part of the elbow. If you are right handed, it most commonly afflicts your right elbow.

This tendonitis of the elbow can be very painful and can cause pain to radiate down the forearm to the hand. It can also cause a weakness of your grip and make it difficult to hold your racquet. It can also be associated with entrapment of the nerve at the elbow, called radial tunnel syndrome. This causes pain, numbness, and tingling in the thumb and index finger of the hand and can eventually lead to permanent nerve damage if not treated properly. This can also put quite a damper on your stroke so it is important not to ignore it and to seek advice from a sports medicine physician. Early treatment is the best way to avoid long term problems.

Conservative treatment often is a good treatment option for lateral epicondylitis.

Here are some simple tips to avoid getting tennis elbow:

1) Regularly do stretches of the forearm muscles to promote flexibility of the muscles and tendons of the forearm and hand. By keeping the elbow straight, stretch the wrist both directions to work the forearm muscles.

2) Squeeze a tennis ball or some other rubber ball for at least five minutes a day. This can be done while driving home from a stressful day at the office or even at work while on the telephone.

3) Do wrist curls using a very light weight and then do reverse curls of the wrist, all with the elbow straight to work the forearm muscles.

4) Always stretch before and after playing. If the elbow is sore after playing, ice the area for at least 15 minutes after playing.

5) A brace worn around the forearm while playing can also help reduce the strain around the elbow and helps give your elbow a break.

If your elbow pain does not go away, it may be time to seek medical attention from a qualified sports medicine physician as most of these injuries can be treated without surgery. Other useful information about common injuries can found at the American Academy of Orthopaedic Surgeons website at www.aaos.org or www.orthoinfo.org with more information concerning all types of orthopaedic injuries.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

Fitness Manual

 

This is the Fitness and Exercise Manual used by the Firefighters of Los Angeles County. Used by permission of its author and patient of Dr. Stetson: Robert J. Karwasky, MS, CSCS, Exercise Physiologist. Select the format of your choice…DOWNLOAD MANUAL

Shoulder Anatomy

The shoulder is a mobile joint that allows the arm to move in many different directions. It is a ball and socket joint but, unlike the hip joint, which has a deep socket for the ball of the hip to fit into, the shoulder socket is very shallow. It has been compared to a “golf ball” on a tee.” The surrounding muscles and ligaments provide stability to keep the shoulder in the socket and allows for a removable range of motion.

The glenoid is the socket of the shoulder joint. It is made of bone and its surface has a smooth layer, called articular cartilage.

The humeral head, or the head of the humerus, fits into the glenoid. The humeral head also has articular cartilage. The glenoid and the humeral head make up the shoulder joint, also know as the glenohumeral joint.

The labrum is a piece of fibrous tissue made of a different sort of cartilage, called fibrocartilage, which surrounds the glenoid. It forms a rim like structure which aid in stabilizing the joint and provides an attachment for the ligament of the shoulder. The labrum can tear which can lead to the shoulder being unstable, or dislocating out of the socket.

The acromion is a bone located on the top of the shoulder joint. It can have a hook of bone in front which can pinch the rotator cuff and the bursa leading to impingement or bursitis.

The bursa is a fluid-filled sac that helps cushion the rotator cuff so the muscles and tendons can move smoothly. The bursa can become inflamed and lead to bursitis (Impingement).

The rotator cuff muscles surround the shoulder joint and act to move and stabilize it. There are four different  rotator cuff muscles. They attach are four different rotator cuff muscles. They attach to the humeral head by way of tendons. When these tendons get irritated, it is tendinitis. When these tendons actually tear, either partially or completely, from the humeral head, this is what is known as the rotator cuff tear. Unfortunately, complete rotator cuff tears do not heal and must be reattached surgically.

The ligaments of the shoulder are thickenings of the shoulder capsule or sac that surrounds the shoulder joint. The ligaments are cord-like and help to stabilize the shoulder joint and keep the ball within the socket.

The clavicle, or collarbone, is the main bone that connects the shoulder to the rest of the body. The acromioclavicular joint is made up of where the acromion meets the clavicle. It is stabilized by ligaments. When these ligaments become damaged, sprained, or torn, it is called shoulder separation.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

What is Shoulder Arthroscopy

An Arthroscope is small, pencil sized instrument which has specialized fiber-optics with a light at the end. These fibers beam a light into your joint and this projects a picture back to a television monitor in front of your surgeon. This allows the surgeon to view inside of your shoulder to see what is damaged.

The Arthroscope is placed into your shoulder joint through a small, quarter inch incision called a “portal.” One or two other small incisions or portals are also made which allows your surgeon to insert other instruments inside of your shoulder to see what is damaged.

The Arthroscope is placed into your shoulder going through a small, quarter inch incision called a “portal.” One or two other small incisions or portals are also made which allows your surgeon to insert other instruments inside of your shoulder. These specialized instruments can help remove damaged tissue., smooth rough edges, remove bone spurs, and even repair ligaments or tendons such as the rotator cuff.

These small incisions means less pain after surgery and quicker recovery as compared to open surgery. Almost all patients are allowed to go home the same day of surgery.

Dr. Stetson is at the forefront of treating complex shoulder injuries with the latest arthroscopic techniques.

What are the advantages of shoulder arthroscopy?

Using advanced surgical techniques we can now treat many rotator cuff injuries using the arthroscope. Many rotator cuff injuries can now be fixed using advanced arthroscopic techniques, which means smaller incisions, less pain after surgery, and faster rehabilitation.

To view Sports Medicine Animations for extensive information on many orthopedic and sports medicine topics, click > HERE

William B. Stetson, MD
Associate Clinical Professor
University of Southern California Keck School of Medicine
Department of Orthopaedic Surgery

Good News and Bad News About Cortisone Injections

Cortisone Patient Education

Non-operative Treatment of Joint Pain

WHAT IS CORTISONE?

Corticosteroids are a class of steroid medications that closely resemble cortisol, a hormone naturally produced by the adrenal glands. Corticosteroids are used to reduce the inflammation, swelling and pain caused by a variety of diseases including osteoarthritis, bursitis and tendonitis. Examples of corticosteroids include Celestone, Kenalog and methylprednisolone (Depo-Medrol) which can be injected into tissues or joints, as well as others that can be taken orally, applied topically to the skin, or given intravenously for systemic circulation.

IS A CORTISONE INJECTION A TEMPORARY REMEDY?

Corticosteroids relieve pain by reducing inflammation. While the inflammation for which corticosteroids are given can recur, corticosteroid injections can provide months to years of relief when used properly. These injections can also cure diseases (permanently resolve them) when the problem is tissue inflammation localized to a small area, such as bursitis or tendonitis. Injections reduce inflammation caused by mechanical damage, but cannot heal tears or ruptures of muscles, tendons or ligaments.

WHAT ARE CORTISONE INJECTIONS USED FOR?

Local cortisone injections can be used to treat the inflammation of small areas of the body. Examples of conditions for which local cortisone injections are used include:

  • Bursitis (inflammation of a bursa)
  • Tendonitis (inflammation of a tendon)
  • Arthritis (inflammation of a joint and cartilage degeneration)
  • Plantar fasciitis

WHAT ARE THE ADVANTAGES OF CORTISONE INJECTIONS?

Corticosteroid injections can relieve localized inflammation of a particular body area more rapidly and powerfully than traditional anti-inflammatory medications given by mouth, such as ibuprofen, aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs). They also can avoid certain side effects that accompany many oral anti-inflammatory medications, notably irritation of the stomach. The injections can also be administered easily in our office.

Cortisone injections administered directly into a knee, shoulder or elbow joint that is immobilized by inflammation, can be beneficial by rapidly reducing inflammation and pain and restoring function. A cortisone joint injection can also decrease inflammation in other diseased joints in the body as the corticosteroids are absorbed from the joint into circulation throughout the body. It is important to note that although potential adverse reactions (described below) can occur, when used properly in low, intermittent doses, cortisone injections present little risk of significant side effects.

WHAT ARE THE DISADVANTAGES AND SIDE EFFECTS OF CORTISONE INJECTIONS?

Short-term complications are possible, but uncommon. They include:

  • Local bleeding from broken blood vessels in the skin or muscle
  • Soreness at the injection site
  • Atrophy at the injection site
  • Depigmentation (lightening of the skin) at the injection site
  • Aggravation of inflammation in the area injection because of reactions to the corticosteroid medication (post-injection flare)
  • Tendon weakening
  • Brief facial flushing
  • Elevation of blood sugar in people who have Diabetes
  • Mild suppression of the immune system in people with active infections

Frequent administration of high doses of cortisone, which is not clinically recommended, is accompanied by more long-term risks. These include, tendon weakening and rarely tendon ruptures when cortisone is injected directly into the tendon, thinning of the skin, easy bruising, weight gain, puffiness of the face, acne, elevation of blood pressure, cataract formation and osteoporosis. Frequent administration of corticosteroids into a joint, which again is not clinically recommended, may have additional side effects including thinning of the joint cartilage, weakening of ligaments of the joint, increased inflammation due to crystallization of a corticosteroid and joint infection.

HOW ARE CORTISONE INJECTIONS GIVEN?

The medical professional administering the injection draws up the corticosteroid into a syringe. A slow-acting numbing, pain-relieving local anesthetic, such as marcaine may be simultaneously drawn into the syringe, and/or a more rapid-acting local anesthetic such as lidocaine may be drawn into a separate syringe to be injected prior to the corticosteroid.

Next, the affected area that will be injected is prepared and cleaned with a local anti-septic. Ethyl chloride spray is used to topically anesthetize this area with rapid cooling and the needle is inserted into the inflamed joint or tissue. The cortisone is then injected into the affected area. The needle is withdrawn and a sterile bandage is applied to the injection site.

If there is excessive fluid within the joint, the physician often will remove it with a separate needle and syringe prior to the injection of cortisone. Removal of this fluid reduces pain and swelling in the joint. The fluid may also be sent to a laboratory for analysis. In addition, this aspiration may aid in a more rapid healing process.

POST-INJECTION INSTRUCTIONS

  • R.I.C.E. – Rest, apply ice, use compressive bandage, elevate as needed.
  • If you are diabetic, regularly check blood sugar, as the cortisone injection may cause an increase in your blood sugar. If your blood sugar level rises, call PCP or other or managing physician.
  • Resume regular activities as tolerated within 10-14 days.
  • It often takes at least 2 weeks for the injection to take its full effect. The injection may last 6-8 weeks or even longer, and in some cases the pain may never return.

REFERENCES

Driver C, Shiel W, Stöppler M. Cortisone Injection (Corticosteroid Injection) of Soft Tissues & Joints. MedicineNet. Last referenced May 2013.

http://www.medicinenet.com/cortisone_injection/article.htm

Interested in Posture shirts?

Read what Dr. Stetson had to say to the Wall Street Journal > WSJ Article

Tennis Pro Dave Hagler Discusses Tennis Elbow and Tennis Shoulder

tennis injuries fall into 2 broad classifications – overuse and deceleration. According to a 2004 USTA study, about 2/3 of all tennis injuries are overuse injuries. These suggestions are for the upper body – tennis shoulder and tennis elbow.

Causes

Tennis players frequently have a muscle imbalance because their internal rotators (used for serves and forehands) are stronger than external rotators.  This is true for players who hit backhands either one or two handed.    In most instances, tennis elbow (lateral epicondylitis) is the result of poor technique which may be exacerbated by hitting backhands with a forehand grip.  If you slightly hyperextend your arm (usually a result of miss hitting a volley or by hitting lots of topspin serves) you can also make tennis elbow worse.  Less frequently a player may get medial epicondylitis (also called forehand tennis or golfer’s elbow), and this is almost always an overuse injury.

Suggestions

1.  Use proper technique. If you are not sure that your technique is correct, go to a reputable teaching professional.  Ask this pro questions, and see if the answers make sense – and do this prior to taking the lesson.

2.  Warm up gradually. Start at the service line and hit there for several minutes.  Hit softly but move quickly and try to follow through completely on every shot.

3.  Don’t hold your racquet too tightly.  Dr. Howard Brody (professor emeritus from the University of Pennsylvania) contends that no human is strong enough to prevent a racquet from twisting laterally on off-center hits.  If a tennis ball is shot into a racquet that is held in a vise or free standing on a table it will leave the racquet with the same velocity.

4.  Use the right type of string. There are two basic types of strings – poly based strings and softer strings.  Many players now combine these two types by using one (typically the poly) for the mains (long strings), and the other (a softer real or synthetic gut [nylon]) for the crosses.  If you use a poly based string you should reduce the string tension for these strings by about 10%.   Stiffer strings move less – when a tennis ball strikes the ground, the ground does not move but the ball flattens out and then bounces up.  Stiff strings do not move much and the ball flattens out on the strings in much the same way it does when it hits the ground.  Soft strings “pocket” the ball and then the ball “shoots” out of the racquet when the string bed flattens out.  Poly is tougher on joints because the dwell time (time the ball is on the strings) is shorter.  Use softer strings!

5.  String at the right tension. A study done by Rod Cross, (Associate Professor in Physics, University of Sydney Australia) found that 11 out of 18 professional satellite players could not distinguish a difference of 11 lbs. provided they did not have auditory cues which would help determine string tension.  Cross, Brody and other physicists contend that a 10 lb. difference in string tension results in a less than 1% change in ball velocity.  What does change is the trajectory of the ball.  If you have elbow or shoulder problems decrease your string tension by at least 5 lbs.  Initially you may lose control, but after a few days you should be able to keep your shots in the court.

6.  Use a standard length racquet. Long, very light, stiff and powerful racquets contribute to injuries.  Many racquets that are very light if you place them on a scale are very head heavy.  It may be easier to swing a racquet that is slightly heavier and more evenly balanced.  If you have shoulder or elbow problems you would be better off using a racquet that is 105 sq. inches or less and of moderate weight.  Factors to consider are weight, length and balance point.  If you want a formula for the swing weight of a racquet, it is available on the net.

7.  Adjust your grip size. There are two opposing schools of thought on this, and each makes sense.  One is to use a larger grip because a player will tend to have more tension (in the forearm) if they use a smaller grip which they tend to squeeze.  The other is to use a smaller grip because this will increase the maneuverability of the racquet.  If you have backhand tennis elbow I would suggest putting an extra overgrip or two on your racquet.

8.  Use surgical tubing to strengthen your external rotators. Stand next to a pole and attach (wrap) the tubing around the pole at elbow height.  Let your arm hang at your side, then lift your hand so you end up with your forearm parallel to the ground and your hand facing 90 degrees forward.  Keep your elbow close to your side and pull the tubing so your arm forearm ends 80 – 90 degrees out (your palm is facing forwards) from where you started.  You should be able to do 3 sets of 10 repetitions without strain.

9.  Wear some sort of band or neoprene sleeve for tennis elbow. There are many good products on the market that will help reduce the strain on your tendons.  You may find that wearing one in the short or long term is of great benefit.

If you have a rotator cuff problem there are other simple exercises that can help.  Go to www.familydoctor.org and search for “rotator cuff” or simply click on the following link:
http://familydoctor.org/online/famdocen/home/healthy/physical/injuries/265.html

Dave Hagler is USPTA Master Professional and PTR Pro based in Los Angeles, California.  Dave is a 2001 graduate of the USTA High Performance Coaching Program.  He has received service awards from the Southern California and Intercollegiate Tennis Associations.  Dave has spoken at coaching conventions on topics including anticipation, games based teaching, and maximizing potential at all levels. He has been published in Addvantage, TennisPro, Tennis, SmashTennis and on www.TennisPlayer.net.  Dave’s articles have been translated into Dutch, Italian, German, Spanish and Japanese. He is a member of the Head/Penn Advisory Staff.

If you have questions you may email him at dave.hagler@sbcglobal.net

Hyaluronic Acid Injections for Knee Arthritis

WHAT IS HYALURONIC ACID?

Hyaluronic acid is a gel-like mixture that is made up of hylan A fluid, hylan B gel, and salt water. Hylan A and hylan B are made from a substance called hyaluronan. The human body also makes its own hyaluronan. Hyaluronan is present in very high amounts in joints. The body’s own hyaluronan acts like a lubricant and a shock absorber in the joint and is needed for the joint to work properly

WHAT ARE HYALURONIC ACID INJECTIONS USED FOR?
Hyaluronic acid injections are used to relieve knee pain due to osteoarthritis. Osteoarthritis is a type of arthritis that involves the wearing down of cartilage (the protective covering on the ends of your bones).  These injections are used for patients who do not get relief from physical therapy, or relief from simple painkillers such as acetaminophen, or non-steroidal anti-inflammatories such as ibuprofen.  In osteoarthritis, there may not be enough hyaluronan, and/or there may be a decrease in the quality of the hyaluronan in the joint.

WHAT OTHER TREATMENTS ARE AVAILABLE FOR OSTEOARTHRITIS?
If you have osteoarthritis, there are other things you can do besides getting Hyaluronic acid injections, these include:

NON-DRUG TREATMENTS:

  • avoiding activities that cause knee pain
  • exercise
  • physical therapy
  • removal of excess fluid from your knee
  • arthroscopic surgery

DRUG THERAPY

  • pain relievers such as acetaminophen and narcotics
  • drugs that reduce inflammation (signs of inflammation are swelling, pain or redness), such as aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen
  • steroids that are injected directly into your knee (such as cortisone)

HOW IS SYNVISC AND HYALURONIC ACID GIVEN?
The doctor will inject 2 mL of Synvisc or a similar substance made by a different manufacturer (Orthovisc, Eufflexa, Hyalgan) into your knee once a week, for three weeks (a series of three injections in total).

ARE THERE ANY REASONS WHY YOU SHOULD NOT RECEIVE SYNVISC INJECTIONS?

  • You should not be given Synvisc or similar injections if you have an allergic reaction to Synvisc or hyaluronan products
  • You should not be given these type of injections if you have a knee joint infection, skin diseases, or infections around the area where the injection will be given

THINGS YOU SHOULD NOW ABOUT SYNVISC AND HYALURONIC ACID INJECTIONS:

  • Synvisc and other types of hyaluronic acid injections are currently only FDA approved for the knee, and is performed only by a doctor or other qualified health care professional
  • Tell your doctor if you are allergic to products from birds, such as feathers, eggs and poultry
  • After you receive the injection, you may need to avoid activities such as jogging, tennis, heavy lifting, or standing for long periods of time for the first day or two after an injection.
  • Hyaluronic acid has not been tested in pregnant women or women who are nursing. You should tell your doctor is you think you are pregnant, or if you are nursing a child.
  • The safety and effectiveness of Synvisc and similar hyaluronic acid injections have not been tested in children.

POSSIBLE SIDE EFFECTS:

  • Pain, swelling, heat, or redness around the injection site
  • Fluid build-up around the knee
  • Rare cases of knee joint infection have been reported
  • Rare cases of rashes, hives and itching have been reported
  • Less common side effects: muscle pain/cramps, flushing or swelling of your face, fast heartbeat, nausea, dizziness, fever, chills, headache, difficulty breathing, swelling in your arms or legs, prickly feeling of your skin, low number of blood platelets

HOW LONG WILL THE INJECTION LAST?
The injections often give pain relief for anywhere between three and six months, and sometimes longer. Notably, there is a chance that the injections will not help.
If the injections help for a period of time, however the pain returns, the series of injections can be repeated.

HOW CAN I GET MORE INFORMATION ABOUT SYNVISC, OTHER TYPES OF HYALURONIC ACID INJECTIONS, AND ABOUT OSTEOARTHRITIS?
For more information about Synvisc, you can call Genzyme Biosurgery at 1-888-3SYNVISC. You may also visit the Genzyme Biosurgery website at www.synvisc.com.

For more information about Eufflexxa, Orthovisc, or Hyalgen, you can visit their respective websites:

Euflexxa: www.euflexxa.com

Orthovisc: www.orthovisc.com

Hyalgan:  www.hyalgan.com

For more information about osteoarthritis, you can visit www.orthoinfo.org or speak with Dr. Stetson about what options might be best for your knee.

If you would like to proceed with these injections, please contact Dr. Stetson’s medical assistant, Suzie, at (818) 848-3030 or you can email her at Suzie@stetsonpowell.com.  We will then contact your insurance company and, if approved, we will contact you to schedule your appointment to start the injections.

Click here to download this information as a PDF: Synvisc and Hyaluronic Acid

Greater Quadriceps Strength May Protect Against Cartilage Loss in Knee Osteoarthritis.

A study published in the January issue of the journal Arthritis & Rheumatism finds that greater quadriceps strength may protect against cartilage loss at the lateral compartment of the patellofemoral joint, and may result in less knee pain and better physical function. The authors studied 265 patients (154 men and 111 women, mean age 67 years old) who were participating in a prospective, 30-month natural history study of knee osteoarthritis (OA). The researchers measured quadriceps strength at baseline, isokinetically, during concentric knee extension. They used magnetic resonance imaging to measure cartilage loss at the tibiofemoral and patellofemoral joints at baseline, 15, and 30 months. Knee pain and physical function were also measured at baseline, 15 months, and 30 months follow-up. No association was found between quadriceps strength and cartilage loss at the tibiofemoral joint. In malaligned knees, the results were similar. However, greater quadriceps strength was protective against cartilage loss at the lateral compartment of the patellofemoral joint (for highest versus lowest tertile of strength, odds ratio 0.4 [95 percent confidence interval 0.2, 0.9]). Patients with greater quadriceps strength had less knee pain and better physical function .

Greater Quadriceps Strength May Benefit Those With Knee Osteoarthritis

Main Category: Arthritis / Rheumatology
Also Included In: Seniors / Aging
Article Date: 14 Jan 2009 – 6:00 PST

Studies on the influence of quadriceps strength on knee osteoarthritis (OA), one of the leading causes of disability among the elderly, have shown conflicting results. In some studies, decreased quadriceps strength is associated with greater knee pain and impaired function, while other studies show mixed results on the effect of quadriceps strength on the structural progression of knee OA.

Most studies to date have used X-rays to indirectly measure cartilage loss in knee OA and have focused on the tibiofemoral joint (the main joint in the knee where the thigh and shin bones meet). A new study has examined the effect of quadriceps strength on cartilage loss (measured using magnetic resonance imaging [MRI]) at both the tibiofemoral joint and the patellofemoral joint (where the thigh bone and knee cap meet) as well as on knee OA symptoms. The study was published in the January issue of Arthritis & Rheumatism (http://www3.interscience.wiley.com/journal/76509746/home).

Led by Shreyasee Amin, M.D., M.P.H., of the Mayo Clinic, the study involved 265 men and women participating in a 30-month study of symptomatic knee OA. At the beginning of the study, participants underwent MRI of their more painful knee and measurement of quadriceps strength for the same knee. They were also asked to rate the severity of their knee pain and their physical function was assessed. The knee MRI and assessments of their knee OA symptoms were repeated at 15 and 30 months. A measurement of knee alignment was also performed.

The results showed that greater quadriceps strength had no influence on cartilage loss at the tibiofemoral joint even in those with knees that were out of alignment. However, stronger quadriceps were shown to protect against cartilage loss in the lateral compartment (outer part) of the patellofemoral joint, a site of frequent cartilage loss, pain and disability in patients with knee OA. The study also showed that those with the greatest quadriceps strength had less knee pain and better physical function than those with the least strength.

Previous studies had also shown no overall protective effect of greater quadriceps strength on cartilage loss at the tibiofemoral joint. The protective effect against cartilage loss at the lateral compartment of the patellofemoral joint is a new finding that needs to be confirmed in future studies, but does provide evidence as to the benefit of having strong quadriceps muscles in patients with knee OA. “Our findings, which also include an association of greater quadriceps strength with less knee pain and physical limitation over followup, suggest that greater quadriceps strength has an overall beneficial effect on symptomatic knee OA,” the authors state. This effect may be due to a strengthening of the vastus medialis obliquus (a quadriceps muscle that pulls the kneecap inward), that may stabilize the kneecap and help prevent cartilage loss behind part of the knee cap.

Although the study did not involve exercise training to strengthen the quadriceps, there have been several short-term studies that show that improving quadriceps strength has a beneficial effect on knee pain and function. “While our findings suggest that maintaining strong quadriceps is of benefit to those with knee OA, further work is needed to determine the type and frequency of exercise regimen that will be both safe and effective,” the authors conclude.

—————————-
Article adapted by Medical News Today from original press release.
—————————-

Article: “Quadriceps Strength and the Risk for Cartilage Loss and Symptom Progression in Knee Osteoarthritis,” Shreyasee Amin, Kristin Baker, Jingbo Niu, Margaret Clancy, Joyce Goggins, Ali Guermazi, Mikayel Grigoryan, David J. Hunter, David T. Felson, Arthritis & Rheumatism, January 2009; 60:1; pp.189-198.

Source: Sean Wagner
Wiley-Blackwell

Read the abstract…

Dr. Stetson is a Big Believer That Age is Not a Factor

ACL Reconstruction in Patients Over 50!

Dr. Stetson is a big believer that age is not a factor when it comes to anterior cruciate ligament (ACL) reconstruction. If you are active and have torn your ACL and want to return to your passion for sports, reconstructive surgery can help.

According to the results of a study published in the November issue of the Journal of Bone and Joint Surgery—British, reconstruction of the anterior cruciate ligament (ACL) in carefully selected patients aged 50 years or over can achieve results similar to those in younger patients, with no increased risk of complications. The research team reviewed the records of 34 patients aged 50 years or over who underwent primary ACL reconstruction (35 knees) between 1990 and 2002. Overall, 23 knees were reconstructed with patellar tendon allograft, and 12 with patellar tendon autograft. The authors noted postsurgery improvements in mean knee extension and flexion, Lachman grade, International Knee Documentation Committee scores, and Lysholm scores. Three graft failures (8.6 percent) required revision.

Anterior Cruciate Ligament Reconstruction In The Over 50s

03 Nov 2008

The Journal of Bone and Joint Surgery, British Volume today publishes ground breaking research on the new use of anterior cruciate ligament reconstruction in patients over 50 years old. The authors reviewed 34 patients over 50 who had received the treatment between 1990 and 2002 and conclude that ‘reconstruction of the anterior cruciate ligament in carefully-selected patients aged 50 years or over can achieve similar results to those in younger patients’.

ACL reconstruction is normally only carried out on 18 to 30 year old patients who lead active lifestyles, whereas older patients frequently receive non-operative treatments such as modification of their lifestyles, bracing and physiotherapy. However, recent studies have suggested that these treatments result in a high rate of re-injury when patients return to moderate activity levels.

One of the reasons this surgery has not been performed on patients over the age of 50 may be anxiety about potential complications, however the study disputes this by showing that only two of the 34 patients required revision. Therefore, the authors conclude that while the sample may be small it is likely that ‘the clinical and functional results of ACL reconstruction in patients aged 50 and over are similar to those in younger patients with no increased risk of complications’.

MEDICALNEWSTODAY.COM

The Journal of Bone and Joint Surgery – British Volume is a world leading orthopaedics journal with an Impact Factor of 1.868. JBJS-Br publishes twelve issues a year of high-quality, peer-reviewed research, overseen by an international editorial board led by Editor James Scott.

The Journal was first published in 1948 by The British Editorial Society of Bone and Joint Surgery, a registered charity (No. 209299), with the object of the advancement and improvement of education in orthopaedic surgery and allied branches of surgery and the diffusion of knowledge of new and improved methods of teaching and practicing orthopaedic surgery in all its branches. You can find out more about The Journal at http://www.jbjs.org.uk

Source
Becky Hall
Journal of Bone and Joint Surgery, British Volume
http://www.jbjs.org.uk

Article URL: http://www.medicalnewstoday.com/articles/127922.php

Copyright ©2008 William B. Stetson, MD
Stetson Powell Orthopaedics and Sports Medicine
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Dr. Stetson’s Research Into Knee Arthroscopy

Dr. Stetson’s research into knee arthroscopy and the use of two portals for knee arthroscopy has led to a new technology by the company Cannuflow. Using two portals instead of three for knee arthroscopy has been proven by research to accelerate the recovery of the quadriceps muscle following knee arthroscopy > Read more

New Technique Videos by Dr. Stetson on the Following:

AC Joint Osteoarthritis and Distal Clavicle Resection.

Shoulder Arthroscopy and Bursocopy.

Arthroscopic Rotator Cuff Repair of a Delaminated Rotator Cuff.

The Basics of Elbow Arthroscopy.