Rotator Cuff Tear Surgery

Posted December 7, 2014 by Orthopaedic Specialists

Massive Chronic Rotator Cuff Tear –

Researchers in Lyon, France, at the Santry Orthopaedic Center wanted to find out if certain rotator cuff tear patterns were associated with loss of range of motion. Philippe Collin M.D. and colleagues published a peer-reviewed article in the September 2014 Journal of Shoulder and Elbow Surgery specifically trying to identify rotator cuff tear patterns and whether they caused pseudoparalysis.

Pseudoparalysis is a condition secondary to rotator cuff pathology, where a person is unable to actively forward flex their arm. This can be a devastating condition for an individual.

Relationship Between Massive Chronic Rotator Cuff Tear Patterns and Loss of Active Range of Motion of the Shoulder

The research group looked at 100 individuals with massive rotator cuff tears. Individuals with fatty infiltration of Goutallier stage III were included in the study. The patients within divided into five groups on the basis of tear pattern. The five different groups involved a tear pattern of: 1) supraspinatus only, 2) superior subscapularis, 3) inferior subscapularis, 4) infraspinatus and 5) teres minor. They measured the patients active range of motion in each group.

Researchers found that active range of motion was significantly decreased in patients with three tear patterns involved. Pseudoparalysis was found in four out of five of the cases with a supraspinatus and complete subscapularis tear.

Pseudoparalysis was noted in only 45% of the cases involving a supraspinatus, infraspinatus and superior subscapularis tear. Loss of active external rotation was related to tears involving the infraspinatus and teres minor. Researchers found that the greatest loss of active internal rotation was related to tears involving the subscapularis.

Pseudoparalaysis and Mass Rotator Cuff Tear

Pseudoparalysis is a devastating condition for patients with rotator cuff pathology. This study revealed that if the entire subscapularis and supraspinatus tendon is torn, or three rotator cuff muscles are torn, then the patient is at risk for pseudoparalysis. (more…)

Ulnar Collateral Ligament Injury

Posted November 25, 2014 by Orthopaedic Specialists

Ulnar Collateral Ligament Injuries in the Throwing Athlete

A great review article on ulnar collateral ligament injuries of the elbow in the throwing athlete was published in the May 2014 Journal of American Academy of Orthopedic Surgeons. This is an important topic given that UCL reconstructions have increased approximately 10 fold in the first decade of the 21st century.

The review article was written by Jeremy Bruce M.D. and James Andrews M.D. Dr. James Andrews has taken care of more elbow injuries in professional throwers than any other orthopedic surgeon in the world. He has performed the Tommy John operation over 2,000 times.

Mechanism of Elbow Injury

Repetitive valgus forces on the throwing elbow can place abnormal stress on the joint. In the thrower, many times the chronic wear predisposes throwers to an acute injury. During the mechanism of throwing, a significant valgus force is placed on the elbow. This is located on the inner side of the elbow. The inner side of the elbow is stabilized by the UCL (ulnar collateral ligament) as know as the Tommy John ligament.

The ulnar collateral ligament elbow reconstruction was first performed by Dr. Frank Jobe on a professional baseball player named “Tommy John” therefore the procedure has become known has the Tommy John procedure.

There are three bundles or sections that make up the ulnar collateral ligament of the elbow: 1) oblique, 2) posterior and 3) anterior bundles. The anterior bundle provides the main valgus support in the pitching motion and is the main restraint to valgus force from 30 to 120 degrees of elbow motion.

Patient History

Some patients will report an actual pop that occurs when throwing. Other athletes report just a vague pain that affects pitching accuracy or velocity. Most patients will report pain with late cocking and the acceleration phase.

Physical Examination

Make sure to check the ROM of the elbow and shoulder to evaluate for motion deficits, especially glenohumeral internal rotation and total rotation. Failure to address abnormal shoulder kinematics can be detrimental to the outcome of UCL injuries. Sometimes an ulnar collateral ligament elbow injury starts as a compensatory mechanism because of a shoulder problem.

Differential diagnosis for medial (inner sided) elbow pain includes the following:

Medial epicondylitis
Flexor pronator injuries
Ulnar neuropathy and apophysitis

Stability Testing

In complete or partial tears of the ulnar collateral ligament there may be little to no laxity that can be detected on physical examination. Named phyiscal tests for UCL injuries include: the milking maneuver, moving valgus test, and the valgus extension overload test.

Imaging Studies

Plain X-rays are obtained to look for arthritis changes, bony UCL avulsions, traction spurs and calcification in the UCL and/or poteromedial olecranon osteophytes. The most common findings on plain films are olecranon osteophyte formations and calcifications within the ulnar collateral ligament (UCL).

MRI testing can help define the soft tissue anatomy . An MRI arthrogram will give more detail and give more accurate results as compared to a plain MRI scan. The T- sign is seen when a pathological amount of dye leaks down along the sublime tubercle but is contained under the superficial fibers of a partially torn UCL. This is the most common finding seen on an MRI arthrogram.

Preventing Ulnar Collateral Ligament Injury

Studies have examined youth pitchers and found that players who pitched more than 100 innings a year had a 3.5 times greater chance of sustaining a serious injury. With this in mind, it is advisable that young pitchers are limited to 100 innings in any calendar year.

It may also be recommended that youth players do not play baseball year round to ensure a period of active rest from throwing in the off season. Youth pitchers are also discouraged from pitching for multiple teams and showcases because doing so has been associated with elbow pain and a potential elbow injury.

A ten year prospective study revealed that overuse is the biggest risk factor for injury. Some of the research results include:

– 500% increased risk for surgery in youth pitchers pitching more than 8 months a year.

– 400% risk for surgery in those pitching over 80 pitches per game

– 250% risk for surgery in those that could throw a fastball > 85 mph

It is also recommended to limit curve ball pitching at an early age because of the high level of neuromuscular control needed to throw with proper mechanics.

Further Education Needed To Reduce Elbow Injury Risk For Throwing Athletes

Education is still needed to reduce the risk of elbow injuries for throwing athletes. A recent study on public perception of pitching showed that 31% of coaches, 28% of players and 25% of parents did NOT believe that the number of pitches thrown was a risk factor for injury.

An equally scary statistic is that 51% of high school athletes, 37% of parents and 30% of coaches think that UCL (Tommy John surgery) reconstruction should be performed on players WITHOUT an elbow injury to enhance performance.

USA Baseball Medical / Safety Advisory Committee Recommendations of Days of Rest After a Pitching Event

Age (years). 1 day of rest 2 days of rest 3 days of rest 4 days of rest

9-10 21-33 pitches 34-42 pitches 43-50 pitches. 51 + pitches

11-12 27-34 35-54 55-57 58 +

13-14 30-35 36-55 56-69 70 +

15-16 30-39 40-59 60-79 80 +

17-18 30-39 40-59 60-89 90 +

Non surgical management of an UCL Injury of the Elbow

Rest. For a partial UCL tear: 6 weeks of no throwing while undergoing physical therapy
Mechanics. Address pitching mechanics, shoulder kinematics and shoulder motion deficits as well as strengthening of the core, lower extremities and upper extremities during the 6 week rehab period.
Gradual Increase in Activity. Once the patient is pain free and the kinetic chain deficits have been addressed, an integrated gradual throwing program may be started

It is very important that the return to a throwing program is gradual and guided by a skilled physical therapist or athletic trainer in order to keep the athlete pain free until competitive play is allowed.

Surgical Management for UCL Injury

Use of an allograft is recommended: ipsilateral palmaris longus or the contralateral gracilis tendon is used in patients without a palmaris longus.

Outcomes After Surgery For A UCL Injury

– Average of 4 months after surgery to return to throwing

– Average 11 months to full competition

– 83% of throwers will on average return to the same level of throwing and competition

Summary

Prevention of an ulnar collateral injury (UCL) is best and is achieved through limiting the number of pitches with appropriate number of rest days. Partial tears of the ulnar collateral ligament can be treated non-operatively. Full thickness tears of the UCL do well with surgical intervention

Torn ACL and Surgery

Posted November 16, 2014 by Orthopaedic Specialists

Torn ACL and Surgery – Learn More About Risk of Re-Tearing

The incidence of second ACL injuries in the first year after ACL surgery is 15 times higher compared to an athlete that has never had a torn ACL.

We have data looking at recurrence rates after one year post surgery for a torn ACL. Dr. Mark Paterno and Dr. Timothy Hewitt and colleagues studied a group of athletes from the time of ACL surgery until they were 2 years post surgery for a torn ACL.

Key findings from this important research on ACL injuries after ACL surgery include the following:

Having another ACL injury 2 years from the date of surgery is 6 times greater in patients that have undergone an ACL reconstruction, compared to the healthy control group that never had any injury.
The group that underwent an ACL reconstruction and then returned back to sport had a 5 times greater rate of recurrent ACL injuries compared to the healthy control group.
Female patients in the ACL reconstruction group were twice as likely to suffer a contra-lateral knee injury as compared to an ipsilateral knee ACL injury.
Overall, approximately 30 percent of the athletes sustained another torn ACL within 24 months of returning back to sports. Out of the 30 percent that had a second torn ACL: 80 percent tore the opposite knee from the initial injury and 20 percent re-tore their surgical side/graft.

Based on the results of this study, we can conclude that the opposite knee is at increased (more…)

ACL Knee Surgery and Knee Injuries

Posted November 6, 2014 by Orthopaedic Specialists

Knee Surgeries and College Athletes

– What are the effects of prior knee surgery including ACL knee surgery on subsequent injury, and surgery for NCAA college athletes?

It is known that college athletes that have undergone knee surgery in the past are at risk for addition injuries to their knee.

There is an excellent study by C. Rugg and Colleagues (2014) that quantified the risk of additional knee injury and knee surgery in a group if division 1 college athletes that had undergone knee surgery prior to entering college.

A total of 456 division 1 athletes entering college were included in the study group.

The college athletes, that had surgery prior to entering college, were divided up into four different groups. The groups included the following:
– 22%: undergone some type of orthopaedic surgery (shoulder surgery, knee surgery, etc.)
– 10%: knee surgery prior to admission to college
– 3.5%: ACL knee surgery
– 6%: multiple surgeries

The group of college students that had undergone knee surgery prior to their admission to college had a risk of a repeat knee injury 6.8 fold more than the control group and there was a 14 fold increased risk of undergoing additional knee surgery.

The group of college students that had ACL knee surgery prior to admission to college had a 19.6 fold increased risk of sustaining an additional knee injury and an 829 fold increase in undergoing additional knee surgery while in college when compared to the control (more…)

Best Shoes for Travel

Posted October 30, 2014 by Orthopaedic Specialists

5 Tips for the Best Shoes for Travel –

Whether you are going on vacation, or traveling for business, learn 5 helpful tips for the best shoes to pack for travel.

1. Bring shoes you can slip in and out of easily. If you are flying, this is especially helpful at the airport, making it easier to go through security.

2. Pack flip flops to wear in your resort, condo or hotel shower so that you do not pick up a foot fungus.

3. If you are in a sunny location, the best shoes for travel cover the tops of your feet or apply sun block to this easily overlooked area. The skin on the top of the feet is very sensitive and can burn easily when exposed to sun.

4. If you are wearing new sandals, remember to throw some band aids into your bag just in case you start to develop a blister. The top part of your foot is very sensitive and new sandals may have different pressure points that cause your skin to tear.

5. If you are traveling to a cold / winter destination, it is important to make sure that your boots are slightly larger and definitely not smaller than your regular shoe size. Tight shoes or boots in cold weather results in colder toes. (more…)

What Are Orthotics including Custom Orthotics?

Posted October 27, 2014 by Orthopaedic Specialists

An orthotic is a device that is placed inside your shoe to help correct foot malalignment. An orthotic, including custom orthotics, is a supportive insert that fits into your shoe.

Orthotics can help people with foot pain and common foot conditions such as: plantar fascitiis, foot pronation, patella femoral pain, bunion deformities, metatarsalgia, posterior tibialis tendinitis, posterior tibialis tendon ruptures / tears, stress fractures and Achilles tendinitis, just to name a few.

3 Different Types of Orthotics including Custom Orthotics

There are three different types of orthotics: 1) custom, 2) semi-custom and 3) off the shelf.

Custom orthotics are the best type of orthotic. Custom orthotics fit your foot perfectly and are specifically designed for your foot type and alignment. A healthcare provider who is certified in making custom orthotics will measure your foot. This typically involves creating some type of cast of your foot to get precise measurements.

The different type of healthcare providers that can make orthotics are: physical therapists, orthotists, and podiatrists. Typically after the custom orthotics are made there will need to be minor adjustments completed once you have tried the orthotic on inside your shoe.

How to Buy Custom Orthotics?

Most insurance plans will pay for custom orthotics. Another option if your healthcare provider does not include orthotics as a benefit is an off-the-shelf orthotic that is heated in the store and molded to your foot. These typically run about $30 to $50 dollars a pair. A large percentage of running shoe stores will carry this option.

Be careful of “Foot” stores that claim to make custom orthotics and are actually pulling an off-the-shelf device and just molding it to your foot. These places sometimes charge hundreds of dollars and your money is best spent with a true pair of custom orthotics (more…)

Foot Bones Quiz

Posted October 16, 2014 by Orthopaedic Specialists

How Much Do You Know About The Bones In Your Feet? Take this quiz about foot bones and find out!

Q 1. How many bones are in your foot?

A. 26

Q 2. Can you name all the bones in the foot?

A. Calcaneus, talus, navicular, cuneiforms, cuboid , metatarsals, proximal phalanx, middle phalanx and distal phalanx (also known as phalanges)

Q 3. Can you be born with an extra bone in your foot?

A. Yes, it is called an accessory navicular. Most of the time they do not cause any problems. It it does become problematic it can be removed.

Q 4. Does your foot have any bones encased in a tendon?

A. Yes, you have two on each foot. They are called sesomoids. They are located under the great toe joints they can become fractured in runner.

Q 5. Can your shoe size get larger after you have stopped growing taller?

A. Yes, however it is not from the foot bones growing longer. It typically has to do with bunion formations or tendon ruptures that can change the shape of the foot and make a larger shoe size needed. (more…)

Do You Have Foot Pain? It’s “Be Good To Your Feet Month” At Orthopaedic Specialists

Posted October 13, 2014 by Orthopaedic Specialists

Louisville’s Orthopaedic Specialists is celebrating “Be Good To Your Feet Month” to offer some relief to those suffering from foot pain. Board certified orthopedic surgeon and sports medicine physician Dr. Stacie Grossfeld is focusing on the importance of healthy feet and foot care to eliminate foot pain during the month of October.

With 26 bones in each foot, 33 joints, over 100 ligaments, and around 125,000 sweat glands, the team at Orthopaedic Specialists emphasizes that caring for your feet is an important part of health and wellness.

As an orthopedic surgeon and sports medicine doctor with a private practice in Louisville, Kentucky, Dr. Grossfeld is accustomed to seeing patients with foot pain and a wide range of foot injuries and problems. This month Orthopaedic Specialists is focused on offering educational information and preventive tips to help people treat their feet a little better. Some upcoming blog topics include: plantar fasciitis, bunions, orthotics, the best footwear, and much more.

While people of all ages suffer from some type of foot pain or injury, foot problems tend to become increasingly common as people get older. Many seniors experience some type of foot injury or problem, and this can cause pain and disability, paired with problems with mobility and independence.

Some common foot conditions that Dr. Grossfeld sees at her Louisville orthopedic and sports medicine practice include: osteoarthritis, bunions, plantar fasciitis, blisters, toe deformities, bone fractures, heel spurs, stress fractures, and tendinitis.

While basic foot care is important to everyone, certain athletes may be prone to specific types of foot injuries and problems. For example, football players may be more likely to suffer from turf toe, while some long distance runners may be prone to plantar fasciitis and ballet dancers may be more likely to experience pain under their big toe caused by sesamoiditis.

If you are suffering from some type of foot pain that is not going away, you may need to seek help from a qualified medical provider like orthopedic surgeon Dr. Stacie Grossfeld at Orthopaedic Specialists. (more…)

Rotator Cuff Surgery and Risk for Recurrent Tearing

Posted October 9, 2014 by Orthopaedic Specialists

Factors Predicting Rotator Cuff Tears that are at Risk for Recurrence Tearing at the Time of Surgery

Once the rotator cuff is repaired what are the chances of a tear recurring? There have been multiple studies completed to verify risk factors for recurrence of re-tearing of the surgically repaired tendon.

Surgical reconstructed is recommended on symptomatic patients that have full thickness tears and have partial thickness tears that involve over 50% of the tendon. One of the most common postoperative complications in reference to rotator cuff surgery is a recurrent tear.

Even after surgical reconstruction the rotator cuff can re-tear. There have been studies reporting recurrent tear rates from 11 to 94%. What are the risk factors that would indicate a surgically repaired rotator cuff could re-tear? Risk factors that have been identified in prior studies are: large tear size measuring from anterior to posterior in addition to medial and lateral tear size ( retraction distance) , surface area of the tear size, older age of the patient, the existence of fatty replacement of muscle , presence of muscle atrophy and quality of the torn tendon.

The above factors have been reported in smaller sized studies typically under 200 patients. The biggest study to date with the most amount of patients was reported in the May, 2014 issue of the American Journal of Sports Medicine. The study was led by Brian Le MD from the University of South Wales, Sydney, Australia. Their study included 1,000 consecutive patients who it undergone a primary rotator cuff repair by a single surgeon using arthroscopic technique.

Six months after the rotator cuff surgery an ultrasound was completed to assess the repair integrity. The authors found that the most important factor in predicting recurrent tearing of the rotator cuff was the size of the rotator cuff tear at the index surgery. The research team also found a strong relationship between recurrence rates in patients who had poor tissue quality, poor intra operative tendon immobility and had a second surgical procedure performed in the shoulder at the time of the rotator cuff tear.

In addition, the researchers found that a patient’s age at the time of rotator cuff surgery was a strong independent predictor of recurrent tear rates, with increasing age linked to increasing likelihood. When comparing the rotator cuff tear size from side to side versus the distance the tear was retracted, they found that the side to side tear size was more (more…)

Nineteen Key Facts About Anterior Traumatic Shoulder Dislocation

Posted October 2, 2014 by Orthopaedic Specialists

1. Almost half of the people suffering from a shoulder dislocation are between 15 and 29 years of age.

2. Males dislocate their shoulders three times more than females.

3. A quarter of the people who have an anterior shoulder dislocation will require surgical stabilization secondary to persistent instability.

4. Half of the patients who sustain a first episode of shoulder dislocation will most likely experience two more episodes.

5. Moderate to severe osteoarthritis has been reported in 18% of patients with a first time dislocation, and up to 40% of patients who have more than one shoulder dislocation.

6. Recurrence rate following nonsurgical management of traumatic shoulder dislocation ranges from 30% to 67%. This rate increases to 55% up to 82% in young male athletes.

7. The biggest risk factors for recurrent instability after shoulder dislocation includes: young age, athletic activity, male gender, and the presence of a bony Bankart lesion. There are some studies that have concluded that males, that play contact sports, under age 20 are the highest risk for recurrence of anterior shoulder instability after first time this location.

8. Nonsurgical management is the initial treatment of choice for first time dislocators. It is recommended that the athletes be in a sling for up to 1 to 4 weeks. Range of motion is typically started at one week post injury.

9. Stabilizing structures at risk after dislocation: the glenoid labrum, the bony glenoid rim, the anterior capsule and the anterior band of the inferior glenohumeral ligament

10. The shoulder is at risk for dislocation because of its wide range of motion, a shallow glenoid articulating with a nearly spherical humeral head. This makes an inherently unstable configuration relying on other structures to prevent instability, including static structures such as the glenoid labrum, joint capsule, and the glenohumeral ligaments.

11. The glenoid is pear-shaped and measures 5 cm in its position from top to bottom and 2.5 cm and it’s inferior anterior posterior dimension. It is relatively shallow with a concave any measuring 2.5 mm deep.

12. The labrum increases the depth of the glenoid by 2.5–5 mm. The capsule provide the negative hydrostatic pressure between the humeral head and glenoid making it more stable.

13. The anterior inferior rim of the glenoid is important to anterior inferior glenohumeral stability. During an anterior shoulder dislocation, the glenoid rim may have avulsed at the bony attachment of the anterioinferior capsulolabral complex. (more…)