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Rotator Cuff Part 4

In April, our annual meeting of the Arthroscopy Association of North America took place in San Francisco. This is the premier society for arthroscopic surgeons (I was the first woman admitted to the Association over 20 years ago). Approximately 2000 surgeons came and there are always new things to learn. 

One of the common themes running through the weekend was that it takes much longer for a patients’ real function to improve than we tell them it will take for rotator repair. In other words, we should help our patients have realistic expectations for when they will be “all better”.  We, as surgeons, tell our patients that after rotator cuff repair surgery, they are going to get better in four months or so. This IS true for day to day activities. I usually tell patients it will take 4-6 months to really feel like you have your shoulder back for day to day activities. This is because some patients get stiff postoperatively (if you are a middle aged female or have diabetes, for example, you have a higher risk for getting stiff- so you should work harder avoiding it) Others’ just sail through their rehab. EveryBODY is different. The consensus at the meeting is that we tell our patients shorter time periods for recovery, because our patients would freak out if they hear that it might be up to a year for all their strength, sporting activities and work function to be as close to normal as possible. I think it is always best to be as honest and clear as you can with a patient in terms of expectations> Although some surgeons act and may even think they ARE the well, ummm, god, we aren’t, and it is our responsibility help you have as realistic expectations as we can. I know I have lost a few patients to other surgeons for just that reason, just because of that, but I do sleep better at night.

In fact, it does take much longer for the shoulder to completely get back to as close to 100% as possible, because the tissues take a long time to mature, the muscles to strengthen and for the whole shoulder to work as a unit again.  So, if you have had rotator cuff surgery, be patient, continue to do exercises, do not be discouraged, and keep in mind that your symptoms will get better up to at least a year if you keep working on your exercises.

-Lesley J. Anderson, MD

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Rotator Cuff Part 3

A few weekends ago, our annual meeting of the Arthroscopy Association of North America took place in San Francisco. This is the premier society for arthroscopic surgery (I was the first woman admitted to the Association many years ago). Approximately 2000 surgeons came and there are always new things to learn.  One of the common themes running through the weekend was that it takes longer for patients’ real function to improve than we tell them.  We as surgeons tell our patients that after rotator cuff repair surgery, they are going to get better in four months or so. Frankly it is because our patients would freak out if they hear that it might be up to a year.  In fact, it does take much longer for the shoulder to completely get back to as close to 100% as possible, because the tissues take a long time to mature, the muscles to strengthen and for the whole shoulder to work as a unit again.  So, if you have had rotator cuff surgery, be patient, continue to do exercises, do not be discouraged, and keep in mind that your symptoms can get better up to at least a year if you keep working on your exercises.

-Lesley J. Anderson, MD

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Rotator Cuff Part 2

The last blog dealt with understanding what the rotator cuff is and basically an overview about rotator cuff.

 How do I know if I have rotator cuff problems?

Contrary to popular belief, history and physical examination is still an incredibly accurate way to diagnose whether you have a rotator cuff problem.  An MRI is not always necessary.  If you have rotator cuff disease, you will have pain during or after an activity.  It will usually be located on the side of your shoulder and occasionally radiates down towards your elbow, but not below it.  Sometimes it will go up towards your neck, but that is usually if it is more severe.  If you have pain which wakens you from a sound sleep, it is much more likely you have a complete full-thickness tear.  Weakness with reaching and overhead work is also a sign of a partial or complete tear. 

Initial treatment of rotator cuff problems, in the acute setting can be use of ice 2-3 times a day and be really careful about your posture, keeping your shoulder blades back and down, and Aleve or Advil on routine schedule for several days, 5-7 days.  These are things that you can do to help at home, but if the pain does not get better, and you need to finally go to the doctor, some of the preliminary treatments have already been done.

Now that you have figured your rotator cuff problem, what is the next step?

As I mentioned, history and physical examination are still the gold standard and are amazingly accurate if done thoroughly for diagnosing rotator cuff pathology. I will next do an office ultrasound to examine the rotator cuff, which is convenient, accurate and less expensive than an MRI. You also do not have to go into a closed tube!

 I personally believe that MRI should be done if:

1.       I cannot figure out what is going on in my history and physical.

2.       If I am considering surgery on a patient, then it will help you in the decision making process.

3.       If there has been 6 weeks of treatment and the pain continues

4.       The ultrasound suggests a tear.

There are lots of variations in the quality of MRI scans as well as those reading them.  Closed MRIs are far superior to open MRIs in terms of quality and accuracy.  If you are claustrophobic, then Valium can also be given before the test to sedate you.  If that is not useful, then we will obtain an open MRI or a test called CT arthrogram could be done.  If it is positive, then the next step will be to discuss surgical options.

– Lesley J. Anderson, MD

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Rotator Cuff Tears

There was a pretty good article in the Wall Street Journal a few weeks back on rotator cuff tears by Laura Londro.  I thought I will explain the next couple of blogs on rotator cuff injuries/problems.  The rotator cuffs are a group of four muscles that come off the shoulder blade or scapula and attach to our humerus/arm and allow us to lift our arm up overhead.  A vast majority of problems occur in the supraspinatus because the blood supply to this particular tendon is the most at risk when you lift your arm away from your body.  The rotator cuff has to glide under the bony archway, the acromion, when you lift your arm to the front and to the side.  Any problems with the attachment of the rotator cuff to the bone can cause pain. 

The rotator cuff will start to degenerate as early as our 20s where pain that develops at that point in time is mostly related to overuse, an aggressive game of tennis, and is rarely seen as a primary problem in someone less than 30.  Shoulder pain in someone under 30 with the diagnosis of rotator cuff is usually due to another cause such as an unstable shoulder with the rotator cuff becoming secondarily inflamed. 

Between 30 and 50, the rotator cuff becomes more degenerated mere replacing the word “tendonitis” (which means inflammation with tendinopathy) which means more related to degeneration.  Over the age of 50, the rotator cuff will further degenerate at a normal process of aging and either develop partial tear which can be small or complete.  Therefore, the cause of rotator cuff problems only depends on one’s age.  Under 30, look at your technique of performing your sporting activities, make sure the diagnosis is correct as instability is also in the cause of “rotator cuff problems under 30.”  Between 30 and 50, the cause of rotator cuff problems is usually due to weakness of the scapular muscles and this is an age group where the training technique, physical therapy, and conservative treatment can often be very valuable. 

Over 50 and only can the rotator cuff be a source of pain but there are other areas that could be the source of pain including the cervical spine, arthritis in the shoulder joint or in the AC joint.  So careful physical examination is important.  Other causes of pain between 30 and 50 are calcium deposits and bone spurs that can cause mechanical pinching of the rotator cuff also which can be treated successfully surgically to prevent progression to cuff repairs.

The next blog will involve discussing how you know if you have a rotator cuff problem.  Then we will discuss the various treatments nonsurgical and finally the surgical treatments of rotator cuff problems.

– Lesley J. Anderson, MD

http://online.wsj.com/article/SB10001424052748703905404576164251084032340.html

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BOOMERS! PLEASE HAVE SOME COMMON SENSE!

As you know, the first of the Boomers turn 65 this year. It is clear that Boomers are entering the Medicare years kicking and screaming. There is a new catch phrase in my office which is: “that is unacceptable.”  I am not going to state that we have to stop doing most things because we are older.  However, there needs to some common sense.

I had a lovely 65-year-old woman come in this week who was petite, approximately 5 feet 2 inches and weighed about 115 pounds, in great shape.  She did not look her age and her complaint was that she could not be as “vigorous” as she wanted to be. 

I asked her what vigorous meant.  She stated “I cannot do deep knee bends with the rest of the class nor I can do lunges like I used to because my knee hurts after I am done.”  Well this was “not acceptable.”  She had no pain during walking; bicycling, climbing stairs or hiking.  It turns out she had a little bit of mild arthritis in her knee and a degenerative meniscus tear.  She has seen another orthopedist who told her she should have surgery.  Mind you, the only pain she had was after she did her vigorous activity.  After spending some time explaining to her that it is normal for our knees to age.  The type of tear she had was not the cause of her pain, but it was due to the overload she was placing on her knee by doing lunges and deep squats.  Surgery definitely would not fix this. 

No one denies that it is extremely important that we keep moving as we age.  Walking, bicycling, and swimming are excellent activities to keep our cardiovascular health, muscular strength, and endurance.  Light weight lifting is also well known to be able to enhance muscular tone and improve the way our bodies look.  When I asked the patient why she was so focused on these “vigorous exercises.”  She states that she wanted to stay in shape.  Granted, these are exercises to stay in shape if you are 20 or 30 years old, but in an aging body these two exercises can cause significant compression through the knee joint, stress fractures, meniscus tears that require surgery.

When I asked her if she knew what the biggest cause of orthopedic disability was in older patients, she was not sure. I indicated that the answer were balance problems – and the falls it causes. You can fracture your hips and break your wrist.  It is known that a hip fracture over the age of 70 has a very high incidence of death within six months. That IS unacceptable. The reason why we fall is that we loose our balance- you trip over the phone cord, the sleeping dog, a bump in the sidewalk. Boomers can reduce the chance of this happening,  

When I told her this she stated “oh my balance is awful.” So, activities like tai chi, standing on one leg and throwing a ball against a wall, and Pilates, are all excellent activities for enhancing our balance.  Boomers, we all need to stay strong, walk, and keep our heart healthy.  Please use common sense when choosing exercises and remember that you have to balance your goals of exercise which includes feeling and looking healthy, with the goals of keeping your overall health which includes being mindful about the activities you choose to do, listening to your body, and using common sense.

– Lesley J. Anderson, MD

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A little perspective to our electronic health records

As most of you know, the new health care legislation puts a lot of pressure on physicians to implement electronic medical records in our offices.  In fact, there are supplements and subsidies for those who do so.  I thought I would just put a little perspective on using them as I have had them in my office for the last 11 years.

There area a lot of advantages for using EMRs.  The main one is communication with all the office staff.  Gone are all the little yellow stickies, post-it notes, messages on my telephone, patients calling on weekends for refills and not knowing if they were in fact my patient or what they need. Communication between health care providers will be one of the greatest benefits of the electronic medical records.

On the other hand, studies have shown that it takes physicians 15% more time to do the same amount of work than before electronic health records.  Of course, this makes the folks at Medicare quite happy in that we are required to now document more clearly very important things than an orthopedist’s examination such as what your great grandmother died of, remote past medical history etc.  It used to be that I would review the very detailed history form you fill out when you come to the office, and that was good enough.  Now we have to actually document all the details in electronic format so that if our charts are ever audited that we have dotted our “i” and crossed our “t” to get paid for the level of service that we have billed for.  This will be a great fund of information for the auditors and their HMOs to track.  We do not really have a problem with this because obviously we should never charge for something we did not do.

However, millions of dollars that this will require will take away from direct patient care in the name of saving money and another level of paper and paperwork extra staff have to do. What IS important is that doctors still take the time with the patient, spend time looking at them, not a computer screen, are able to touch, lay hands and examine completely, reassure, and comfort the patient when they are distressed, and not worry if you have documented the physical examination properly for the HMO or payors.  I worry that healthcare will go the way of your doctor looking at a computer, never making eye contact, looking at study results, but never listening to your fears and worries, examining your knee or shoulder, and using most of the skills that we spent years learning in medical school and residency in order to provide care and compassion for patients.  Let us hope that our government’s desire for more electronic formatting of patients take the humanism out of your relationship with your physician as well.

-Lesley J. Anderson, MD

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One last thing about Vitamin D

As you know, the last few blogs have been evolved; the value and importance of having your vitamin D3 checked.  There have been a number of articles in the media noting that vitamin D does everything from treat cancer to reduce heart disease to even grow hair! (Just kidding)  Obviously these claims are not my area of expertise and I would certainly take a lot of pause until one looks at the evidence-based studies on these areas and check with your internist

What we do know is that vitamin D is absolutely essential for good bone health.  We are just scratching the tip of the iceberg in terms of its effects.  I cannot tell you how many patients coming in to my office with knee pain that are middle-aged men that I get vitamin D levels on, are dramatically low. The Bay Area has one of the lowest Vitamin D levels in general in the country.  Women on the other hand, are generally within normal limits and that may be because they are a lot more conscious about taking vitamins and calcium supplements.  For men, I urge you to take at least 1-2000 mg a day especially if you have darker skin since you do not tend to absorb this well. Get a level checked to see where you are and how much you need to take.

An interesting article in the British Bone and Joint Surgery looked at outcomes of total hip replacement and its relationship to vitamin D levels.  What was surprising is that patients with low vitamin D levels preoperatively did not have as good outcomes as those with normal vitamin D levels.  So this is an exciting area of study and we look forward to more articles looking at how we can improve your bone health, improve your outcomes with surgery, and in any way stay out of our office is in the first place!.  That would be a good thing.

-Lesley Anderson, MD

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More on Vitamin D

More on Vitamin D.  A study put out by the Hospital for Special Surgery in New York reinforces the alarmingly high rate of low vitamin D in patients scheduled for orthopedic surgery.  In a chart review of 723 patients, they found that 43% of all patients had low vitamin D levels, and of those, 40% had severely low levels.  The highest rates of low vitamin D levels were seen in patients in Sports Medicine Services as well as who had trauma or fractures.  Over one half of patients (52%) had low vitamin D levels in patients undergoing sports related surgery!  The highest rate was in patients between age of 18 and 50 years and it was significantly higher in men (5X higher). In patients sustaining fractures, 66% had low vitamin D levels.  In individuals with darker skin tones (Blacks and Hispanics) were over 5 times more likely to have low vitamin D levels when compared with those with lighter skin tones (White and Asians).

Bottom line:  Get your vitamin D level checked.  If you are a runner and have had arthroscopic surgery, I am routinely recommending, particularly in men, to have your vitamin D levels checked and corrected because we are seeing an increasingly high number of stress fractures and bone bruises that occur when patients go back to high-level sports that involved running, jumping, or pounding.  We do not know for sure whether the low vitamin D levels correlate with the reason why one develops this.  On the other hand, it seems like it could be very likely.  You should be taking at least 1000 mg of vitamin D3 tablets a day and I recommend you take it as a supplement unless you drink four cups of milk a day.

Lesley J. Anderson, MD

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Weight Loss

Losing weight during the holidays or any time can be a struggle for many people.  In the Jan/Feb 2011 article in the AARP magazine, Brian Wansink listed some easy ways to cut calories, identify your weakness and tricks to help loose at least 20 pounds in six months. 

Most of our patients have an ongoing battle with their weight. In our practice it is especially important because for every pound you gain puts 4-6 pounds of stress on your knees! Similarly, losing just 5 pounds will take 20 pounds off your knees. Arthritis will progress much faster in an overweight patient in the knee and is a leading cause of need for total knee replacements in patients over 50. As we get older, it comes more difficult to loose the weight.  A few extra calories a day can add up to being 50 pounds heavier in a matter of months.

 Wansink identified a few ways to cut calories.  You eat 22% less by using smaller plates and pour 29% less by using tall, thin glasses instead of short, wide ones.  If you store all your snacks in small-single serving food-storage bags, you’ll eat up to 20% less. 

It’s also important to identify the environment.  By identifying your weakness, you can change the eating environment.  Common weakness including meal stuffing, party binging (I know the holidays are coming up), desktop/dashboard dining, restaurant indulging and snack grazing.  Once you identify the danger zone, you can focus on changing the habit.

Wansink identified 10 easy tricks that helped people loose at least 20 pounds in 6 months. It really is one of the better and more practical guides I have seen.  To see the article for yourself, click below.

http://pubs.aarp.org/aarptm/20110102_PR?folio=42#pg44

Sometimes is nice to have moral support.  Many of my patients found support and great success with FA and Weight Watchers. You also know I will be one of your greatest cheerleaders for your success. It makes for fewer total knee replacements for me and that makes me happy.  

http://www.foodaddicts.org/

http://www.weightwatchers.com/

The main thing about weight lost is to have reasonable goals and to modify the goals as time goes no.  Tracking your progress and reaching your goals not only feels good, but makes you healthier.

Lesley J. Anderson MD

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Slings and Driving

Patients often ask whether or not they can drive in a sling.  This is particularly a problem after some shoulder surgeries, which require that the patient wears the sling for six weeks.  Not only does it feel bad to ask your friends over and over again for a ride to the store or to work, but it certainly cuts into one’s independence.  Well, a study in internal the Journal of Bone and Joint Surgery in October 2010 looked at the safety of driving with an arm immobilized in a splint.  Two groups of patients, one in an immobilizer and the other not, were compared in a driving test using cones or agility, as well as driving time.  In those tests, patients in a fiberglass splint above and below the elbow were compared.  This did not even include a sling.  These were patients that could actually use their shoulder.  Results showed that driving performance was significantly worse with patients in splint immobilization of the arm.

Bottom line; you are putting yourself and others at risk if you are driving with your arm and above the elbow splint. One of our patients recently got a ticket of $1500 for driving with a sling. (Don’t know if he was misbehaving as well.)  In addition, it’s the law in California, just ask one of our police patients.

– Lesley J. Anderson, MD