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Rotator cuff injury- What is the rotator cuff?

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What is the rotator cuff in the shoulder and what is a rotator cuff injury?

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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.

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MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.
***About this video***
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses rotator cuff injury, rotator cuff pain, and shoulder tendonitis.

What is Frozen Shoulder, and How can it be Treated

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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.

 

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***For more educational content:
Sign up for our email newsletter:
https://www.chicagoarthritis.com/newsletter/
See our blog:
https://www.chicagoarthritis.com/blog/
Listen to the Regenerative Medicine Report podcast:
https://www.chicagoarthritis.com/regenerative-medicine-report/

***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
Determine if you are a Regenerative Medicine treatment candidate:
https://www.chicagoarthritis.com/regenexx-candidate-form/
Contact us for more information or to schedule an appointment:
https://www.chicagoarthritis.com/contact-us/

MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

 

What does it mean to have a good result after Regenerative Medicine Treatment for the Shoulder

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It’s always good to understand what is meant by a good response to a regenerative medicine treatment. Sometimes, from the physician’s end what can mean a good response can be different than what it means from the patient’s standpoint. So it’s always helpful to make sure that when we say good response, we’re presenting it from the perspective of the patient.

As an example, I have a new patient that I saw recently who has a left shoulder pain. She is a 70-year-old woman, very high-functioning, and that includes swimming, low-level weights, and cardio three to four times per week. She had an injury to her left shoulder roughly five years ago. She has, at baseline, some mild degenerative rotator cuff tendinopathy and arthritis as well. At the time of her injury five years ago she developed a high-grade partial thickness tear of her supraspinatus tendon. She was treated by a colleague of mine at that time with bone marrow-derived stem cells. She did well for about a year and a half at which time she started to develop early signs of pain again. She had a repeat platelet rich plasma treatment and essentially did well for about three more years.

Currently she is presenting to me now as she has redeveloped discomfort in the left shoulder. She is still very high-functioning, still doing all of her exercises. On her ultrasound examination she still has that high-grade partial thickness tear, it has not gotten worse and might be slightly better. She also has mild inflammation in the biceps tendon, but essentially stable imaging of her left shoulder. The plan for her is to repeat platelet rich plasma treatment because she’s done very well with that a few years ago.

The goals here are can we keep this individual at a very high level of function, with significant pain relief, and not requiring pain medication. If we can keep the imaging look stable or better that’s great, but that’s really a secondary issue. Realistically we are not going to dramatically change how her imaging looks. If it stays stable, as it has over the last five years, that is a successful outcome. But, more than anything else, improving pain, allowing her to stay very physically active at a high level at the age of 70, and avoiding pain medications that is a great outcome. From her perspective that is a great outcome, from the physician’s side that is a great outcome as well. It’s a nice merging of our expectations, and I think she has a good chance of doing really well.

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