Two Issues Reverse Shoulder Therapy May Help Eliminate

19 Sep 2016 Andrew Mahoney, Christopher Stevens, Doctors, Joel Goode, Kevin Bowers, Steven Shapiro , , , ,

The shoulder joint is the most movable and complex joint in the body, therefore the opportunity for complex problems is greater. A few of the more common shoulder conditions are arthritis and rotator cuff injuries.  When both of these conditions are present, it can present a complex problem for the orthopedic surgeon. A relatively new FDA-approved procedure may be the answer:  reverse total shoulder replacement.

A brief review of shoulder anatomy

The shoulder joint is made up of three main bones; the collarbone (clavicle), the shoulder blade (scapula), and the upper arm bone (humerus). The shoulder joint is a ball-and-socket-type joint. The “socket” is a shallow dish-shaped area of the scapula. The top of the humerus bone is round like a ball, and fits into the socket.  The bones are held in place by the rotator cuff, which is made of four major muscles, tendons, and ligaments. The ligaments from the rotator cuff attach directly to the head of the humerus bone and hold the arm in place.

The shoulder joint is the most movable and complex joint in the body, therefore the opportunity for complex problems is greater. A few of the more common shoulder conditions are arthritis and rotator cuff injuries.  When both of these conditions are present, it can present a complex problem for the orthopedic surgeon. A relatively new FDA-approved procedure may be the answer:  reverse total shoulder replacement.

A brief review of shoulder anatomy

The shoulder joint is made up of three main bones; the collarbone (clavicle), the shoulder blade (scapula), and the upper arm bone (humerus). The shoulder joint is a ball-and-socket-type joint. The “socket” is a shallow dish-shaped area of the scapula. The top of the humerus bone is round like a ball, and fits into the socket.  The bones are held in place by the rotator cuff, which is made of four major muscles, tendons, and ligaments. The ligaments from the rotator cuff attach directly to the head of the humerus bone and hold the arm in place.

Rotator Cuff Tear and Arthritis

The shoulder can be injured easily at work, around the house, or during sports or exercise activities. When the cause of shoulder pain is related to your rotator cuff, the simple act of throwing a ball to your grandchild may cause enough pain to drop you to your knees.  In many cases minor rotator cuff injuries can be rehabilitated without surgery, but major damage must be surgically repaired.  In some cases, it may not be possible to fully restore the strength and stability of a damaged rotator cuff.

When your pain is caused by degeneration of soft tissues and the effects of arthritis inside the joint, you can thank the natural aging process. While Mild to moderate arthritis can be managed conservatively with medication, physical therapy, and therapeutic injections; severe arthritis can only be resolved by replacing the joint.

Traditional Vs Reverse Shoulder Replacement

In a traditional shoulder replacement, the ball of the humerus is replaced by a half ball, and the socket is replaced by a “cup”.  This mimics the same anatomy as the original bones, minus the arthritis.  If necessary, the rotator cuff is repaired and reattached to the new joint.  A traditional shoulder replacement is best for patients when the rotator cuff is intact or is repairable.

In a reverse shoulder replacement, the cup is placed on the top of the humerus – replacing the ball – and the ball is placed in the cup – replacing the socket.  See figure below. Reversing the ball and cup placement puts the deltoid muscle in place as the major muscle for the new joint instead of the rotator cuff. A reverse shoulder replacement is also recommended for people with severe arthritis and rotator cuff damage, or prior failed traditional shoulder replacement.  The reverse shoulder replacement procedure was approved by the FDA in 2004.

Am I a Candidate?

Through a comprehensive evaluation by your doctor which can include X-rays, and MRI, the doctors will determine which type of shoulder replacement is best suited for your case.  The extent of damage in your shoulder joint will determine the type of surgery you need.  People with unrepairable damage to their rotator cuff along with severe arthritis are the best candidates for reverse shoulder replacement.

It all starts with a visit to Tucson Orthopaedic Institute, Southern Arizona’s largest and most advanced multi-specialty orthopedic group.  Here, we are able to diagnose your symptoms to determine the best course of action for you. We can perform either a traditional or reverse shoulder surgery, and arrange your physical therapy so you can get back to doing all you like to do.

Several of our orthopedic surgeons are trained and experienced in both traditional and reverse shoulder replacement: Dr. Kevin Bowers and Dr. Christopher Stevens in the Oro Valley office, Dr. Joel Goode and Dr. Andrew Mahoney in the East office, and Dr. Steven Shapiro in the Northwest office.  Call one of our conveniently located offices today to schedule an appointment at Tucson orthopaedic Institute.

Helpful Tips for Post-Operative Elbow, Hand and Shoulder Surgery

28 May 2015 Joel Goode , , , , , , ,

You have just had hand surgery, elbow surgery, or shoulder surgery. These are some helpful hints and frequently asked questions that may help with your recovery and manage your pain.* By staying ahead of your pain and swelling, you do not have to catch up. Remember, an ounce of prevention is worth a pound of cure!

Pain Management

  • Begin taking prescription pain medication given to you the same day of your surgery, BEFORE you go to bed. If you have received a nerve block, there is a good chance you will still be comfortable before you go to bed. However, the block will eventually wear off. Take your pain medication before the block wears off/before you go to bed.
  • The pain can be more manageable if you stay ahead of your pain, and not chase your pain.
  • Itching is a side effect that is quite common to experience after using narcotic pain medication. If you are itching, try over-the-counter Benadryl as directed. This may help to alleviate the itching.
  • However, if you are having difficulty breathing, swelling of the lips, face and/or throat, or a new rash, this may indicate a serious allergic reaction. You should stop taking the medication and alert your doctor or seek prompt medication attention.
  • As for use of anti-inflammatory medication, such as ibuprofen, Aleve, Motrin, etc., after surgery, this depends on your physician preference. Please check on your discharge instructions or ask your physician before or at the time of your surgery.

Nausea/Constipation

  • It is also not uncommon to experience nausea, constipation and sometimes drowsiness with narcotic pain medications.
  • Nausea is a common side effect either from the anesthetic or from the pain medication prescription itself. Make sure you take the medication with food to help prevent nausea.
  • The medication can also slow down your gastrointestinal tract and lead to constipation. If you experience constipation, try eating foods with high fiber, prune juice, and/or over the counter stool softeners (Check with your local pharmacists about stool softeners, if you have any questions).
  • If these are happening, cut back on the amount of pain medication you are taking or stop taking the medication. Contact your physician.
  • Do not drive while you are taking pain medications. They may enable your full capacity. Do not drink alcohol, use illicit drugs, drive or make any important decisions while taking pain medication.

Swelling Control

  • Swelling is one of the things that contribute to your post-operative pain.
  • After your surgery, keep your hand elevated, unless specified not too.
  • If you have had shoulder surgery, elevation of your hand may be difficult. In this case, getting a squeeze ball and making a fist repetitively can help to pump the swelling away from your hand.
  • Elevate your hand above the level of your heart, especially 3-5 days after surgery.
  • Below are some photos showing correct ways to elevate your hand.
  • Ice is an excellent anti-inflammatory and helps control pain and swelling. Apply ice to the surgical site as tolerable (unless specified otherwise). If the discharge information specifies not to ice, then please do not do so. This may be the case in some situations.

Positions to elevate your hand following surgery:

Exercises/Therapy

  • If you have had surgery on your shoulder and/or wrist/hand, it is important to start exercises the day of surgery by making a full fist and straightening your fingers. However, if your surgery was to repair a broken finger, or specified otherwise, follow specific instructions given to you.
  • You may be referred to a formal therapist at your follow-up appointment or subsequent appointments. Therapy is determined by your health care provider and individualized for your specific case.

Dressing/Cast and Sling

  • Do NOT remove your dressing, unless you are told to do so. This will be removed and/or changed at your first post-operative visit. Keep bandage clean and dry.
  • Do NOT get your dressing wet. Protect it with a plastic bag when you shower.
  • If your dressing is too tight, you may loosen the ace/bandage, and split the dressing down on one side; however, do NOT remove the entire dressing/splint.
  • If you are placed in a sling for a shoulder surgery, keep arm in the sling (as pictured below). Do not actively move the operative shoulder, unless told otherwise. You may gently move your hand, wrist and elbow.
  • Seeing blood on or through your bandage occurs and should not be worrisome unless excessive and expanding. You can try to apply some pressure to the area or reinforce the dressing to prevent further bleeding. If excessive and does not stop, call your physician or seek medical attention.
  • If you dressing is off, and while your incision is healing, please refrain from applying any antibiotic cream or ointment to the incision area. Keep clean and dry. Regular antimicrobial soap and water while washing is preferred.

Correct placement of arm sling following shoulder surgery:

Long-Term Management and Expectations

  • After a traumatic injury and/or elective surgery, it is common to experience swelling for several months. Typically, the process will gradually improve over the next 12 months! Try not to get discouraged, because the swelling will most likely improve with time.
  • As time progresses after surgery, the amount of activity will be determined by your physician/health care provider.

*There are many surgeries that are performed on the upper extremity (including surgeries for rotator cuff tear, carpal tunnel syndrome, and trigger finger) with many different post-operative instructions. The information above may not always pertain to you if you were told otherwise on your discharge paperwork and/or by your physician.

Written by Joel R. Goode, MD and Lauren King, PA-C, with contributions by Liz Cakmarstitt, MA

Exercising Caution: Too Much, Too Fast, Too Soon

1 Sep 2014 Doctors, Media, William Prickett , , , , , , , ,

If someday you find yourself sitting around the house with your leg in the air, the limb wrapped in ice and towels – looking like a corn dog – you may need to see a surgeon. William Prickett, MD, an orthopedic consultant for the University of Arizona athletics department (and sports medicine surgeon at Tucson Orthopaedic Institute), has seen it all.

“The most common thing that leads to injury is the proverbial ‘terrible too’s’ – they do too much, too fast, and they do it too soon.” The CDC reports that in 2011, unintentional overexertion was the second-leading cause of non-fatal injuries in people aged 25-55. “I tend to see lots of shoulder problems from overuse injuries related to racquet sports and golfing.”

“In younger patients, in the shoulder, there tends to be more surgery that’s related to instability and it involves reconstructing and repairing ligaments. More common in the weekend warrior or older athlete is rotator cuff work.” 

If, like an automobile manufacturer, Dr. Prickett could recall one body part, it would probably be the shoulder.

“The shoulder is very much dependent on muscles and soft tissues for stability. The range of motion that we have puts that joint at significant risk. The amount of force that we create just throwing a baseball is excessive and sometimes more than I think it was engineered to do.”

Overuse injuries can be prevented by cross training and using good form and technique, according to Dr. Prickett. Overuse injuries are different than acute injuries. “The acute traumatic injuries often are just unlucky,” he says. “Somebody gets injured on a trampoline or playing basketball. They may have been playing for years and for whatever reason they were unlucky that day.”

So what are the signs that you should see a doctor?

“If someone is having difficulty with weight bearing, if their extremity looks different, there’s numbness or tingling, and severe pain that’s not improving – all of those things are red flags saying this is not just muscle soreness.”

Dr. Prickett has some new tools he can use to repair injured joints.

“There have been advances in things such as growth factors and platelets – using your own blood to treat your injuries.”

This is called platelet-rich plasma. “We use a component of the patient’s own blood that is injected back into the site of injury, with the goal of allowing the body to heal itself.”

He also can use tissue engineering, replacing cartilage defects, most commonly in the knee. “There are techniques that allow you to remove small pieces of cartilage, expand them in the lab and then put them back into the defect,” he says.

“The most common thing that we see done now is a rotator cuff repair, which is a shoulder procedure to repair torn tendons.” Historically this was done where the muscle was divided and then the tendon was repaired back to the bone, but now with improvements in arthroscopic techniques it can be done without cutting the muscle.

“This is due to advances in the ability to visualize structures and new instrumentation and fixation techniques,” Dr. Prickett says. “Not only can we see better, but we can manipulate tissue better, and we’ve had advances in the ability to fix tendon to bone.”

Tendons connect muscle to bone, which are different than ligaments that connect bone to bone. “In the shoulder, most injuries occur where the tendon attaches to the bone. You can see weakening of the tendon and tearing of the tendon.” This is where Dr. Prickett gets down to some serious suturing.

“A repair of the tendon is hooking the tendon back into the bone. We have anchors that have suture attached to them, so we put an anchor in the bone. Suture then gets wrapped around the torn tendon and you tie it back together. These type of tendon injuries don’t heal on their own, so you need to repair it,” he says.

Once repaired, the patient may feel a little too good. “One of the struggles we have as physicians with any type of reconstructive procedure is that there are times when they feel great, but it’s not in the patient’s best interest to high load that joint with exercise.”

One way to try and stay out of his office is to take care of your feet.

“There’s been a big trend in barefoot running, but if you can keep your feet covered, I don’t understand why you wouldn’t,” he says. “The key thing is comfort. I see a lot of patients who try new things, new trends. Don’t try to make your foot or your gait fit into something that’s not comfortable for you, because that’s where we see a lot of these overuse injuries. To me it’s a little like trying to put a square peg in a round hole. If it doesn’t feel right, if it hurts, stop.”

He can’t say if he has a favorite procedure he performs. “All of them are interesting and enjoyable on my part, because you get people back to doing things that they want to do. I love working on athletes’ knees and reconstructing their ACL, because it’s exciting to see athletes be able to get back to participate in what they enjoy doing.” He concludes, “It’s just as exciting to see a soccer player get back on the field as it is to see a grandparent feeling comfortable picking up their grandchild.”

For more information about Dr. Prickett, or to make an appointment, please contact the Northwest office.

Excerpt from the September 2014 issue of Tucson Lifestyle Magazine

Written by Owen Rose

Photo credit: Kris Hanning

View the article in its entirety

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