Rotator cuff problems

What is the rotator cuff and rotator cuff pathology?

The rotator cuff is the group of four muscles and tendons that surround the shoulder joint, providing strength and stability. Above the rotator cuff there is a bursa, or sac of tissue, that covers and protects the rotator cuff as it comes into close contact with bones around the shoulder. (see Figure 1) When the rotator cuff is injured or damaged it can lead to inflammation of the bursa (bursitis) causing pain and loss of motion. Thickening of the rotator cuff and its bursa can lead to an impingement syndrome where the tissues impinge against the bones around the shoulder. This can cause pain and further damage to the rotator cuff.  

While some rotator cuff injuries occur in younger people secondary to trauma, most injuries result from aging and degeneration of the cuff tissues. Damage to the rotator cuff can vary from microscopic tears to large irreparable tears. The symptoms of rotator cuff tears include pain, weakness, restricted motion, catching, locking and a feeling of instability. Rotator cuff pathology ranges from a normal, asymptomatic aging process to endstage arthritis and instability caused by absence of the rotator cuff.

Who gets it?

Rotator cuff tears increase in incidence with age, however not all rotator cuff tears are painful and many individuals with rotator cuff pathology are completely asymptomatic. When it does become symptomatic it can present in a variety of ways ranging from minor problems to severe pain and limitation of function. Onset of symptoms can be related to ordinary activities of daily living, or they can be attributed to a single event. The symptoms are usually

aggravated in certain positions, such as reaching back, for example, to fasten a seat belt or picking up a briefcase out of the back seat. Symptoms are worse when the arm is elevated overhead, especially if the elevated

arm is loaded, such as picking up a stack of plates out of a cupboard. Overhead activities (pitching, throwing, tennis, or racquetball) commonly worsen symptoms.

How is rotator cuff pathology diagnosed?

History and physical examination are the best way to initially evaluate rotator cuff pathology. It is important for the doctor to differentiate shoulder pain that may not be coming from places other than the shoulder such as the neck or even the heart. On the exam, pain can be provoked by overhead maneuvers, and there may be weakness of the shoulder muscles. Although plain x-rays do not show the rotator cuff muscles, they are helpful to look for calcifications, arthritis, or bone problems such as spurs that can cause rotator cuff tears. MRI is the most utilized imaging method to diagnose rotator cuff tears.(see figure 2) They can be used to look for tears, inflammation of tissues and to help determine the size and quality of the tear which helps direct proper treatment. Injections and even arthroscopy may be used to diagnose rotator cuff tears.

What are the treatment options?

Alterations in activities and learning to use the shoulder in a safer, more comfortable manner is important. Physical therapy may help improve mobility and strengthen shoulder muscles. Anti-inflammatory medications and injections are used for pain relief and to decrease inflammation. If these treatments fail, then surgical intervention is a reasonable option. Arthroscopy is most often the surgical treatment of choice to remove inflamed bursa and impinging bone spurs. The end of the clavicle (collarbone) may be removed if it has impinging spurs. Often rotator cuff tears can be repaired with arthroscopic techniques. Other tears require a larger incision and surgical exposure. Some large tears, particularly those associated with resultant arthritis, simply cannot be repaired and require major surgical options such as joint replacement surgery.

Rehabilitation

Postoperative treatment depends on the operation done, but therapy is a critical part of the recovery, which can take from three to twelve months. A coordinated effort between the patient, surgeon, and physical or occupational therapist is required.

Rotator Cuff Pathology

Dr.  Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon

and Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached 718-283-7400

Elbow Arthroscopy

What is elbow arthroscopy?

Arthroscopy is a minimally invasive procedure that allows a surgeon to look inside a joint using small incisions (portals) and instruments the width of a pencil. Most people are aware of knee and shoulder arthroscopy but the elbow joint has many conditions that can be treated with arthroscopy as well. The elbow is the joint that connects the upper arm bone and the forearm bones. Because the incisions used with elbow arthroscopy are smaller and disrupt less soft tissue than conventional open surgery, pain, swelling and stiffness are minimized and recovery is often faster.

When is elbow arthroscopy performed?

The role of elbow arthroscopy in the treatment of elbow disorders has been dramatically increasing over the past few years. There are a variety of conditions for which elbow arthroscopy can be useful in diagnosis and treatment, including arthritis, loose bodies in the joint, tennis elbow, stiffness and fractures.  Fractures of the elbow or any injury for that matter to the elbow can lead to significant stiffness of the joint. Release of stiff contracted elbows after injury is a being treated more frequently with elbow arthroscopy. Arthritis of the elbow although not curable by arthroscopy can result in significant improvement in symptoms and function.  After physical examination, X-rays, and possibly other studies such as CT or MRI scanning, your surgeon may recommend an arthroscopic procedure for treatment of your elbow disorder.

How is elbow arthroscopy performed?

The procedure is performed under general or regional anesthesia.  A fiberoptic camera is inserted through a small incision or portal around the elbow. The camera lens magnifies and projects the small structures in the elbow onto a television monitor, allowing the surgeon to accurately diagnose the condition. Several other small portals are used to allow the surgeon to place the camera in different positions to see different structures inside the joint as well as to place various small instruments into the elbow joint to help treat various problems in the elbow. Sometimes elbow arthroscopy is combined with open procedures.

After elbow arthroscopy
After your arthroscopy, you may be placed into an elbow splint that allows full mobility of your hand. The period of immobilization will vary depending on what was performed at the time of surgery. Elevating the involved extremity is important to prevent excessive swelling and pain after your surgery. Certain conditions require that you begin therapy right away and others may not require it at all. Often elbow arthroscopy is done as an ambulatory procedure allowing the patient to go home the same day but occasionally, depending on the condition a hospital stay may be needed.

Risks and limitations
As with any surgery, elbow arthroscopy has risks. These include infection and potential damage to nerves and arteries. Stiffness may need to be addressed through post operative rehabilitation. Elbow arthroscopy is not appropriate for all elbow conditions and is dependent on the surgeon’s training, expertise, and comfort level.


 

Dr.  Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon

and Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached at 718-283-7400.

Shoulder arthritis

Shoulder Arthritis

What is it?

Osteoarthritis or “degenerative joint disease” is the most common type of arthritis about the shoulder. The other less commonly seen types of arthritis in the shoulder are rheumatoid or inflammatory arthritis and arthritis that occurs after severe trauma. In osteoarthritis the smooth cartilage that lines and coats the ends of the bones gets worn away causing the bone ends to rub against each other. This leads to irregular motion within the joint and the development of bone spurs. This can result in pain and loss of motion in the shoulder.  There are 2 joints within the shoulder that can be affected by osteoarthritis. The main joint which provides most of the shoulder motion is called the glenohumeral (G-H) joint which is where the humerus or arm bone meets the scapula or shoulder blade. The other smaller joint in the shoulder which does not provide much motion is the acromioclavicular (A-C) joint which is the joint that connects the collarbone and the scapula. 

Who gets it?

The incidence of shoulder arthritis increases with age. Generally it is seen in people over 50; however younger people can get it after suffering trauma to the shoulder such as a fracture or dislocation. Arthritis of the A-C joint tends to occur at a younger age than arthritis of the main joint of the shoulder the G-H joint. There is a genetic predisposition to arthritis so it can be hereditary as well.

What are the signs and symptoms?

The most common complaint of someone with shoulder arthritis is pain. The pain worsens with activities especially any overhead activities and decreases with rest. Arthritis of the G-H joint usually hurts mostly in the back of the shoulder while A-C arthritis hurts mostly in the front at the end of the collar bone. The next most common complaint is loss of motion which is much more severe in those with G-H arthritis. In addition, the motion of the shoulder can sometimes feel like grinding (crepitus) as the bones move in relation to one another. Fortunately not everyone who develops arthritis develops pain and loss of motion in fact some people with severe joint destruction have very few symptoms.

How is it diagnosed?

Arthritis of the shoulder is easily diagnosed with a physical examination and x-rays. On the physical examination the physician will be looking for pain on range of motion, crepitus or grinding of the joint, weakness of the shoulder and tenderness to touch.   X-rays of the shoulder show loss of joint spaces, bone cysts and bone spurs or osteophytes at the edges of the joint. People with arthritis of the A-C joint are also at risk for developing rotator cuff tears and an MRI may be needed.

How is it treated?

As with most other arthritic conditions, initial treatment consists of rest, activity modifications, therapy and anti-inflammatory medications such as ibuprophen. Icing and moist heat as well as other therapy modalities such as ultrasound may be prescribed. If these treatments do not work to decrease the symptoms then surgery may be suggested. For arthritis of the A-C joint this would involve removal of the end of the clavicle which can be done arthroscopically. For arthritis of the main shoulder joint, surgery usually involves a joint replacement operation where the arthritic surfaces of the bone are replaced with metal and plastic. Sometimes only a portion of the joint needs to be replaced (hemiarthroplasty).

 

Dr.  Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon

and Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached at 718-283-7400.

Orthopedic Research at MMC

Orthopedic Research at

Maimonides Medical Center

Over the past two years, the department of Orthopaedic Surgery at Maimonides has experienced a tremendous growth in its research efforts. Laboratory space, grant funding and dedicated personnel in addition to a renewed commitment by department leadership to expand research efforts have led to the successful completion of over 25 projects in a variety of areas. Several projects have been recognized and awarded by national and international societies. Residents in training as well as faculty are provided with necessary resources and mentoring on study design, statistical methods, data analysis, and manuscript preparation. Completed and ongoing projects span the gamut of orthopaedic specialties with a balance of basic science, bench, animal and clinical research.

Studies on carpal tunnel syndrome have focused on the effects of the disease on sleep patterns. It has been well established that inadequate sleep has detrimental effects on overall health however these effects have never been quantified. A preliminary study of 50 carpal tunnel patients showed a significant correlation to disease severity and sleep disturbances. Ongoing research is geared toward establishing guidelines and monitoring the effects of treatment. Another study on carpal tunnel patients evaluated the compliance and effectiveness of non-operative management of the condition with night splinting and found that while symptoms improved many patients required surgery to alleviate the condition

Other studies in upper extremity surgery have focused on the use of fluoroscopy as opposed to traditional x-rays in establishing diagnoses in a variety of conditions. The fluoroscopy which offers lower dosage radiation was found to be superior in determining severity of carpal malalignment in wrist sprains and assessing the severity of thumb instability following ligament injury. In another study it was found to be superior to x-rays in assessing the position of fixation hardware in fractures of the wrist. The latter study was the recipient of the best poster award at the British Society of Surgery of the Hand annual meeting.

In the field of spine surgery studies are being performed on the use of a saliva test to evaluate DNA markers that can more effectively predict the progression of adolescent idiopathic scoliosis than multiple consecutive x-rays. Children can now be exposed to much less radiation and parents can be provided with objective data in order to help make crucial decisions concerning operative management. Another study on scoliosis has evaluated using less hardware in fusion of the spine, decreasing operative time and significantly reducing costs. 

Another avenue of research has been in the area of cartilage damage and regeneration. One study evaluated the effects of certain medications used to treat the symptoms of arthritis and found that some medications actually can lead to further damage of the cartilage structure. In an animal study on rabbits a previously unknown growth factor in human cartilage Granulin - Epithelin Precursor (GEP) was found to have promising results in regeneration of cartilage. These studies have helped gain further insight into the causes and potential treatments of arthritis. The latter study received the best research award at the Eastern Orthopaedic Association meeting and was invited for special presentation at the American Academy of Orthopaedic Surgery

Research in the area of osteoporosis has become our next challenge. Osteoporosis related fractures are seen in excess at Maimonides and can lead to significant morbidity and mortalities. The prevention of osteoporosis through proper diagnosis and medical management has been reported to be extremely poor throughout the country with estimates of only 20% of patients receiving the proper treatment. An increased awareness of the disease is needed in order to make any progress in combating its effects. To this end we are studying the compliance rates for treatment in identified patients and increasing awareness through patient and physician education.  At the recent New York Orthopaedic Society symposium “Quality and Outcomes 2009: A practitioners guide to documenting excellence of care” our work at Maimonides entitle “Thinking a step ahead: Diagnosis and Management of Osteoporosis for the Orthopaedic Surgeon” was given the best poster award.  Further work in this area will involve the development of a database of patients to follow the effects of treatment and basic science work as well as utilizing nanotechnology to study the effects of various drugs on the prevention of the disease.

The efforts of the department could not have been successful without funding from the Maimonides Research Foundation. Most recently we received a grant in order to study the prevention of debilitating neuroma formation in rats. It is hopeful that through this research, surgeons can be guided to the best techniques to prevent neuromas when operating on nerves.

Preventing Back Pain

Back Pain!

How Do We Prevent Back Pain?

Dr. Juan Carlos Rodriguez

Adult and Pediatric Spine Specialist

Tel: 718-283-6520

Trained in complex spine surgery, Dr. Juan Carlos Rodriguez treats pediatric and adult patients with pain or back deformities. Dr. Rodriguez graduated with MD and PhD degrees from Universidad de Salamanca and Universidad Complutense de Madrid, respectively. He is fellowship trained in Surgery from the Hospital for Special Surgery and in Spinal Surgery from New York University Hospital for Joint Diseases.

·   Exercise, by walking, swimming, jogging, biking, or even gardening, at least 30 minutes each day. 

·   Maintain a good posture when walking, sitting, and even when sleeping.  Don’t slouch – sit in a balanced and neutral position to avoid straining your spine.  Sleep on a mattress that doesn’t slouch, maintaining, even while you sleep, the same natural spinal alignment that you have when standing, allowing muscles to relax.

·   Maintain a healthy weight.  Excessive weight can strain the spine, causing it to wear out.

·   Lift properly by bending from the knees.  Instead of bending from the back and twisting while lifting objects, hold the objects close to your body, with your legs apart, tightening the abdominal muscles, and keeping the object being lifted close to the body. 

·   Strengthen your spine while you do household chores:  When washing the dishes, use the sink to stabilize yourself so you can stand on one leg for about 30 seconds, alternating legs, and building strength in the core muscles of the lower back and abdomen.  When vacuuming, avoid bending and pushing; instead, stand upright with your chest pushed out, and with your legs, rather than your back, moving forward and backward. 

·   What you do in bed matters – when you lift your head to watch TV or to read in bed, your muscles contract, causing back pain.  Instead, place pillows under the small part of your back and behind your neck so that you don’t cause an unnatural position for your spine by slouching, which may cause back pain the next morning.

·   Get up! Too much bed rest can weaken your back muscles and cause loss of flexibility.

·   Don’t sit in one position for too long; take breaks and change positions frequently.

·   Cross ‘em!  Cross your legs, alternating, if you sit for a few hours (such as at school, in a theatre, or in a doctor’s waiting room), to move and stretch the back and hip muscles.

·   Where’s your wallet?  Men are advised to stop sitting with the wallet in the back pocket, as the position can eventually cause chronic pain.

·   Just say “NO!” to lifting heavy weights. 

·   Make sure that your computer screen is at eye level.  Sit with your back straight, don’t slump, and don’t curve your spine too much.  Stretch often to get your circulation flowing better.

·   Drink at least 6-8 glasses of water per day

 

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