Article: A Randomized Controlled Trial of the Treatment of Rotator Cuff Tears with Bone Marrow Concentrate and Platelet Products Compared to Exercise Therapy: A Midterm Analysis. Christopher Centeno, Zachary Fausel, Ian Stemper, Ugochi Azuike, and Ehren Dodson.
What is the rotator cuff in the shoulder and what is a rotator cuff injury?
On this video, you’ll learn about rotator cuff injuries causing shoulder pain. If you’ve ever had pain in the shoulder, you can understand how limiting this sort of injury and pain can be. There are a number of different things that can cause shoulder pain. They can include an injury to the rotator cuff tendons, it can also include a strain to the ligaments around the shoulder, and arthritic component to the shoulder joints. In addition, you can also have pain in the shoulder that comes from the neck whether that’s a pinched nerve coming from the neck or actual arthritis in the neck. In this video however, I’ll be talking and focusing on rotator cuff injuries coming from the shoulder itself.
So what is the rotator cuff. The rotator cuff are four muscles and by extension their tendons that help to stabilize the shoulder joint. These muscles include the supraspinatus, infraspinatus, subscapularis, and teres minor tendons. The biceps tendon is a tendon within the shoulder itself and offers stability. However, it’s not actually part of the rotator cuff. The rotator cuff muscles start at the shoulder blade or the scapula, and then extend to the humeral bone where the tendons then insert. The purpose of the rotator cuff is to stabilize the humeral head and thus the shoulder joint when moving through a range of motion. They do this by the muscles contracting individually, but in a coordinated fashion. The supraspinatus helps the shoulder to abduct or lift the arm above the head. The infraspinatus and teres minor tendons help with external rotation of the shoulder. And the subscapularis tendon helps with internal rotation.
Rotator cuff injuries come in different types. At the most mild there’s tendonitis or tendinopathy which really means irritation to the tendon. There’s any progression where you can then develop rotator cuff tears, which means disruption of the fibers. This is a range in spectrum of injury. Meaning you may start with a rotator cuff tendinopathy and with time and due to instability you can then develop progressive tearing of the tendon. Thinking of rotator cuff tears as a spectrum of injury. There’s a grade one tear where you’ll have fraying or a mild injury to the tendon. A grade two tear where you now have more of a significant partial thickness or a portion of the tendon where the fibers are disrupted. And then finally you’ll have a grade 3 tear where there’s an entire disruption of the fibers of the tendon. In that full thickness tear category, you can have a tendon tear where the edges of the tendon are still closely approximated, and you can then have tendon tears where they are fully pulled apart and retracted.
The usual cause for a rotator cuff tear includes repetitive overhead activity whether that’s at work or with sports or other types of activities anything that stresses the actual shoulder joint and soft tissue around it. In general people have likely had an acute or chronic injury and usually there’s really multiple successive injuries. It can start off relatively mild where there’s a ligamentous injury to one of the ligaments that helps support the bones. That sort of mild injury can then lead to progressive instability which in turn then leads to progressively putting more stress on the rotator cuff tendons, and then eventually leading to enough accumulated damage that leads to a partial and then sometimes even a full thickness tear of the tendon.
What’s interesting is that the degree of tendon tear does not always correlate with the degree of pain it can correlate with a degree of weakness in the shoulder but not necessarily pain. You can have significant pain if you’re still at a relatively early stage of that sort of process. And you may actually have less pain when you have a full thickness tear but it’s important to understand that the degree of damage that you see on imaging does not always correlate with pain and thus even if you have a mild injury, you should consider some sort of treatment at an earlier stage. And even if you have a significant injury that can sometimes still be treated with conservative measures as well.
Symptoms from a rotator cuff injury typically involve pain in the front, the side, or the back of the shoulder. This can go further down the arm as well and even into up into the neck. If there’s a significant tear you can have weakness in the shoulder. Significant instability in the shoulder will lead to impingement or reduce range of motion in the shoulder, and significant pain with range of motion as well.
Diagnosis of a rotator cuff injury and tear involves a good dedicated evaluation by a musculoskeletal expert. First and foremost do you have a pretty good history of a injury pattern or recurrent stress actually on the shoulder. It’s important to be able to differentiate between what is a injury and pain derived from the shoulder versus pain that may be coming from the neck. A good physical exam is very key in that regard. Do you have findings on examination that indicate stress or an injury to the rotator cuff or do you have findings that are more indicative of pain that may be coming from the neck.
Next Imaging can be very helpful. What I recommend first line is generally a basic x-ray of the shoulder to look to see if there’s any bone pathology and then a diagnostic musculoskeletal ultrasound. With ultrasound you can get a really great look at the rotator cuff tendons. You can see the tendons as they move in a dynamic motion. And while you’re moving the arm as well to get a better look at tendons and to see what’s happening when you’re moving through a range of motion to see if there’s any impingement or subtle little tears. MRI does have utility as well. There’s certain things that ultrasound is not as good at looking at. That includes a labral tear which is the ring of tissue around the shoulder joint. As well as if you have any sort of swelling or bone marrow edema within the subchondral space of the bone of the humerus and shoulder bones as well. But when you’re looking at rotator cuff injuries and tears, I personally find that an ultrasound gives you a better and more nuanced look at the actual injuries to the tendon itself.
So now that you understand more about the rotator, cuff rotator cuff injuries, and tears that can cause shoulder pain, tell me if you’ve had shoulder pain, did you have a rotator cuff injury and how was it treated? If you found this content interesting or useful, and you would like to learn more about your musculoskeletal health and wellness consider subscribing to this channel or to my email newsletter.
Thank you for your time. Have a good day and live well.
On this video I’m talking about what is frozen shoulder, how do you diagnose it, when should you be suspicious that you could have it, and what are the treatments that can help you out with your condition.
On today’s episode I’m talking about frozen shoulder also known as adhesive capsulitis, a very painful condition that causes severe limitation and range of motion in your shoulder causing not only pain and significant limitation in activities and abilities. So what is frozen shoulder. Frozen shoulder is a condition that is defined as severe limitation in your shoulder range of motion having ruled out other conditions that could cause that same limited range of motion.
You see this most classically in individuals who are in their 50s or 60s, there’s a slight increase in prevalence amongst women compared to men, and there definitely some significant risk factors that can make you more prone to this including if you have metabolic syndrome which can include active diabetes, uncontrolled hypothyroidism. If you’ve had a recent shoulder injury as well, and if you’re more prone to inflammation in general from various autoimmune conditions.
The cause of frozen shoulder is not that well understood, but the thinking is that there’s an initial inflammatory component, then a neurogenic or neurologic aspect to it, and then eventually a fibrosis part of it that causes significant contractures of the shoulder joint capsule. The capsule is essentially a layer of tissue that surrounds the shoulder joint that adds support as well as stability to the shoulder joint when that gets inflamed and then eventually fibrotic and scar down it leads to significant limitation range-of-motion. Why that occurs is not entirely understood but that transition from inflammation then to fibrosis and contractures and scar tissue is one that is pretty well understood.
There are generally three stages to frozen shoulder. There’s an initial freezing stage which means that there’s a progressive limitation in shoulder range of motion, that’s probably the inflammatory component. There’s then a significant frozen stage where there’s significant contracture and scarring down of the shoulder capsule where the range of motion is then severely limited, that’s probably now the more fibrotic stage. And then there’s a slow progressive thawing where that loosens up. That progression can take anywhere from 6 to 24 months and can leave residual limitation and range of motion. Because of that prolonged course as well as that residual limitation in range of motion that can occur, it’s important to treat this and diagnose it early so that you can improve your overall prognosis long term.
Diagnosis of frozen shoulder requires a few things. Number one a good history to really gauge your progressive loss of range of motion as well as to screen if you could have some other conditions systemically that could be causing this. So for example if you’re at risk for diabetes, if you’re at risk for hypothyroidism, or some other inflammatory conditions, you want to make sure you are properly screened for that if there’s any consideration of a systemic cause for frozen shoulder. Once that’s been done a good examination to help document your level of impairment as well as limitation of range of motion and some imaging.
The imaging that I recommend is a simple x-ray and diagnostic musculoskeletal ultrasound. MRI and CT scans are generally not needed for this diagnosis. You need an x-ray to help make sure you don’t have any other significant bony pathology or arthritic issues that could be causing that limitation or range of motion. And you need a good diagnostic musculoskeletal ultrasound to help screen to make sure you don’t have any significant rotator cuff pathology that could be causing your limitation of range of motion because realistically if you have a rotator cuff injury you will be treated a bit differently than how you would a frozen shoulder. And again the diagnosis of frozen shoulder requires ruling out other conditions including a rotator cuff tear.
I am a bif fan of diagnostic musculoskeletal ultrasound because you can look at soft tissue injuries including tendon and ligamentous injuries in a very quick and detailed fashion you can also examine how limited your range of motion is and how much impingement that restriction is causing your shoulder as well with ultrasound. That is a relatively efficient and quick and easy way to help make this diagnosis.
Early diagnosis and early treatment are key in order to get a good result with this condition. So if you have progressive pain and progressive reduction in range of motion I would recommend getting checked out by your trusted physician by doing a proper relatively focused evaluation you can figure out if you have an early stage of frozen shoulder and if so you can start the treatment for that relatively quickly, which can then help prevent the progression and actually turn it around faster.
First-line treatment for frozen shoulder is typically physical therapy. Physical therapy in a safe and controlled fashion can help you go through a range of motion to try to bring that back relatively faster and quicker. That’s important because they can push you when they need to push you and they can kind of hold back a bit when it’s maybe safer to do so, and I’d recommend going that route first line for sure.
Other traditional first-line options include anti-inflammatory medications and steroids. I would caution both of these. Anti-inflammatory medications can help short term but they have a lot of potential issues longer term. As an example they can increase your risk of stomach ulcers, heart disease, liver damage, and kidney damage. Preferentially I recommend using over-the-counter supplements including glucosamine chondroitin, omega-3, and turmeric. These can help with not only pain but they can also help with inflammation. They are much safer than taking anti-inflammatory medications or chronic narcotic medications and I think if they can help in terms of pain that is a preferable route to use.
In terms of steroids you want to be careful with these as well. Oral steroids by mouth really don’t have any evidence of efficacy for long-term effectiveness of frozen shoulder. Steroid injections on the other hand can help with pain and even help with the symptoms of frozen shoulder. The issue is that steroid injections are not healthy or helpful for the actual tissue of the shoulder whether you’re talking about the shoulder joint or the tendons, and so if there are other options, and there are which I will discuss shortly, I think you’re better off avoiding steroid injections whenever possible. Two other treatments I would caution to avoid. The first is surgery. There is no evidence that surgery is beneficial for frozen shoulder so I would avoid that if possible. The second is manipulation under anesthesia. This is a process where you are sedated or put under general anesthesia and then the surgeon relatively aggressively manipulates your shoulder to give it more range of motion. The risk here is that because you are knocked out and not able to give any feedback that if the range of motion you’re put under is too aggressive and pushes it too far that you may actually damage other soft tissue areas including the labrum, the rotator cuff tendons, and ligaments as well. I think there are better options besides these two which have limited evidence of efficacy and may have some additional risks that are not really worth it.
If you have failed conservative management with physical therapy and over-the-counter supplements, my preferred next step is actually a different type of injection. A safer and better option is what’s called platelet lysate hydrodistension. What’s involved in that is the following- we take a sample of your own blood from a blood draw, concentrate that into a high concentration of your own platelets, then crack open the platelets and just take the growth factors from that. We combine that with a little bit of numbing medication and then inject that into the shoulder joint. We put in enough volume to stretch the shoulder capsule to break apart some of the adhesions and scar tissue, then over the next couple days on your own, while you’re in the office, and then even with physical therapy have them really more aggressively push the range of motion in the shoulder to help loosen it up even further. This is a better option than utilizing a steroid injection which is unhelpful or unhelpful and unsafe for the tissue. Platelet lysate is in fact healthy and safe for your tissue and can be done on a number of occasions repeated to actually help with the frozen shoulder. In addition it’s done in a manner that is done with your own control as opposed to manipulation under anesthesia where you don’t really have control of how aggressive that pushing through range of motion is done, This allows you to control that which is really important from a safety standpoint that you control how this is done. And then lastly this is one that can help accelerate the process of recovery from having a frozen shoulder which makes a difference in terms of your recovery in terms of your ability to gain range of motion and pain relief and functional improvement.
Three other key pearls and notes that you should be aware of. Number, one if you need to be evaluated for a shoulder issue in particular frozen shoulder make sure that you’re getting your neck evaluated as well. A pinched nerve in the cervical spine or an arthritic facet joint in the cervical spine can also translate to not only pain in the shoulder but sometimes also weakness and can affect your range of motion as well. When you see your physician make sure that they’re checking out the neck as well. There are a couple things that they can do by history and examination to determine if you need additional evaluation with imaging as well. Number 2 make sure that if there’s any suggestion that you are prone to systemic inflammation that that gets evaluated and treated appropriately as well. It’s important because excessive systemic inflammation can make you more prone to frozen shoulder and can make it more complicated as well. Number three make sure that if there are signs of risk for metabolic syndrome or other metabolic conditions like poorly controlled diabetes or hypothyroidism that that gets evaluated properly as well, and if needed gets treated as well.
So hopefully this content has given you a better understanding of what frozen shoulder is, when you should be concerned about it, how to be properly evaluated, and what are some best principles when it comes to treatment, and best options for treatment as well.
Question of the day: if you’ve had frozen shoulder and you’ve recovered, how did you get better, what treatment modalities did you pursue, what worked for you.
9 things you can do to treat your shoulder pain without needing to see the doctor.
On this episode I discuss the nine things that you can do if you have shoulder pain without needing to see the
Shoulder pain can be tremendously limiting to your life in that it can cause reduction in your ability to work exercise and do
other activities that make your life enjoyable. I’ve spoken in a prior video about what is going on within the shoulder when you have that sort of pain. Today’s episode is about what you can do to help yourself when you have shoulder pain so that you
can get better and actually avoid needing to see a physician at the same time.
Disclaimer alert, for the vast majority of you who are either watching or listening to this content I am likely not your treating physician. Some software algorithm has deemed it appropriate for us to be communicating together and I am certainly a physician that has information that is useful to you in terms of understanding your shoulder pain as well as how to treat it in a low-risk non-surgical manner. But disclaimer to my thoughts if you’ve had a severe injury, if you’re not getting better with very conservative management only, if your symptoms are progressively getting worse, if you have significant neurologic symptoms like weakness numbness or tingling, or if you’re just concerned that your pain is not progressing in the way that it should,
please get checked out by your actual physician.
So there are a number of things that you can do on your own to self treat your pain if you’ve had a shoulder injury. Some of these may seem really obvious some of these you may not considered before. I would recommend all of them as conservative low risk first-line options to see if you can manage your shoulder pain before having to see an actual physician. Number one is
stop or modify the activity that is actually causing your shoulder pain. This may sound really obvious but the reality is that there are certain activities work-related that may be hard to stop or completely modify if they’re essential to what you’re doing but if
you’re able to change or stop that activity then I would strongly recommend doing so to at least initially stop the pain while you then try to do other things to then rehabilitate the shoulder into a better position.
Option number two is to correct any technique that can be improved with your activity. For example I played tennis when I was a teenager I then stopped as a young adult but then picked it up again in my mid to late 30s. When I started playing tennis again I started to develop pain in my shoulder when I was serving and hitting overheads. My solution at that time was I worked with a physical therapist and a tennis coach did a lot of videotaping of my serve and overhead activity adjusted and modified and improved my technique and that’s made a humongous difference in my ability to continue to do overhead activities with my right shoulder and continue to play tennis as well. So modifying activity is a really important one but even improving your technique is even one step higher.
Bad posture can put a lot of stress on your neck your upper back and your shoulders on the other hand improving your posture can take a lot of stress off of those areas including your shoulder. If your posture is something that could use some improvement I’d strongly recommend working with a clinic like Egoscue that focuses on posture correction technique exercises.
Option number four is to work with a good physical therapist who can help with strengthening the muscles around your shoulder. Strengthening the muscles of the upper back the neck area and around the shoulder makes a big difference strengthening those tissues helps with stability which in turn helps with function range of motion as well as pain as well. Great first line option as well is strengthening all those muscles.
Number five is maximizing the range of motion in your shoulders normal shoulder health includes having a very full and wide range of motion in the shoulder. Anything that you can do either via active range of motion exercises or passive range of motion exercises with a trainer or physio is helpful that can include exercises that they help you out with can even include some hanging exercises but anything that lets you maintain a full range of motion in the shoulder is essential for normal and optimal musculoskeletal health of the shoulder.
Number six is manual therapy that can include massage chiropractic and similar techniques. Anything that helps to relieve the stress on the muscles and myofascial tissues around the shoulder and the neck will help with your shoulder as well. Taking stress off of those tissue planes will help with pain around the shoulder improve range of motion and improve the biomechanics of the shoulder as well.
Option seven are other complementary therapies including acupuncture and dry needling. These techniques can help with myofascial pain as well these are another great low-risk helpful modalities that can help with pain and shoulder health.
Number eight is heat versus ice or thermal therapies.It’s a good adjunctive treatments and should be used in a focused and appropriate fashion. So heat can help in terms of muscle and myofacial pain. Ice or cold therapy or cryotherapy can help with inflammation. It’s important however to be careful with how you’re using cryotherapy or cold therapy. Controlling excessive inflammation is good in particular if you’re talking about chronic inflammation. It’s important to understand that acute inflammation in the setting of a recent injury to some degree is helpful and is required to kick-start the normal healing process. So I think focused cryotherapy and even focused heat can have a benefit long-term as well if it’s used appropriately.
And number nine are certain over-the-counter supplements. The three big ones that I recommend are glucosamine chondroitin, omega-3, and turmeric supplements. Glucosamine chondroitin can help with pain related to osteoarthritis. I think that’s a good option for a lot of people that have musculoskeletal issues. Omega-3 which comes from either fish oil or flaxseed oil supplements and turmeric can help with inflammation and related pain. I think those are definitely preferable to using chronic anti-inflammatory medications or chronic narcotic pain medications and I think those three over-the-counter supplements are helpful for the vast majority of people that have various musculoskeletal conditions as well.
So to sum it up there are quite a few different things that you can do on your own to help yourself if you have shoulder pain and they may allow you to avoid additional medical or surgical intervention. In a follow-up video I will discuss when you actually should see your physician for your shoulder pain, what treatment options may be available to you at that point, including what regenerative medicine treatment options may be helpful to help deal with your shoulder issue.
So question of the day- if you’ve had shoulder pain what have you done to self treat that’s made a difference for your own health.
Thanks for tuning in if you found this content valuable you can subscribe to either my youtube channel or via my email newsletter. If you’d like to learn more see ChicagoArthritis.com.
Thanks for your time, have a good day, and live well.
Why does your shoulder hurt when lifting your arm?
If you have shoulder pain with lifting your arm that can be disabling when it comes to your exercise, work, and other activity. So let’s talk about what’s going on when you have pain in the shoulder. The shoulder is an amazing structure in the human body. It allows you to move your arm in a incredibly wide range of motion in multiple planes and to do so with stability. That stability is maintained by layers of tissue working in a highly coordinated fashion throughout that range of motion.
At this stage it’s incredibly important to understand the concept of biotensegrity. The idea of biotensegrity is that when you take multiple individual subunits that are distinct and independent, if you put them in close approximation to one another under tension and compression, you get a stronger overall unit. In other words, the whole is greater and stronger than the sum of its individual parts. In the case of the shoulder the multiple units that are involved include: Multiple joints, the labrum of the shoulder, the ligaments that help to keep the bones connected together, the rotator cuff tendons, the multiple muscles that are involved, the fascial layers in between the muscles and the tendons, and even the nerves that supply the muscles and tendons.
Due to biotensegrity a healthy shoulder allows you to have coordination, stability, and durability even if you have a mild to moderate injury. A shoulder that has had too severe and injury or chronic injury, can then develop instability, chronic inflammation, pain, and functional loss as well.
As a physician how do I determine what structures are injured and what’s the problem? First and foremost there has to be an understanding that shoulder pain and dysfunction is rarely due to just one structure because of the layers and depth of tissue that are involved. It’s frequently a combination of issues and layers that are involved. Furthermore as a physician I will evaluate your history of pain, your injury pattern, examination findings, and correlate with advanced imaging findings.
Imaging findings that helpful include:
Diagnostic musculoskeletal ultrasound is incredibly helpful for looking at the shoulder in a dynamic range of motion, evaluating the rotator cuff tendons, instability related to the ligaments and other soft tissue structures, joint arthritis, and determining whether chronic inflammation is present as well.
X-rays can be helpful if you have had an acute injury and need to evaluate for any sort of bone injury.
MRI is typically most helpful if you are looking for labral injuries or certain types of bone issues as well. MRI has been used typically also for looking at rotator cuff injuries. In reality due to the dynamic nature of ultrasound you can actually get better information about a rotator cuff tear and compare to the other side if you’re using diagnostic musculoskeletal ultrasound in a skilled, intelligent, and nuanced manner.
Based on the structures that have been injured as well as what other conservative treatments have been pursued, additional medical or interventional procedures can be pursued as needed and required.
To sum up, the shoulder is a wonderfully complicated and layered structure. Injuries to it can lead to instability. Instability in turn leads to chronic stress on the injured tissue as well as the surrounding supportive tissues. That in turn leads to chronic inflammation, which then also leads to chronic pain, functional limitation, reduced range of motion, and disability. In a follow-up set of videos I will go through what you can personally do on your own if you have shoulder pain, when you should see a physician, and how a physician can actually help with your shoulder pain as well.
Let me know your thoughts and perspective. In future blog posts you’ll also learn what you can do on your own to treat your shoulder pain, when to see a doctor, and what else can a physician specialist do to help with your shoulder pain.