Shoulder problems in middle age

What is causing my shoulder pain?

Chances are if you are over 40 years of age that it is rotator cuff tendinopathy, a rotator cuff tear, acromio-clavicular osteoarthritis or a frozen shoulder.
In fact it could be a combination of any of the above.

Rotator cuff problems are very common. They start with pain in the upper arm and the top of the shoulder. Typically there is catching pain on reaching behind for something like in the car. There can be darts of pain and also dull aching. The dull ache is typically worse at night and can prevent sleep. It seems to be worse on lying down. It can settle for no particular reason after a few months. Perhaps physiotherapy can help this or it eases itself with time anyhow.
We used to think that this was a mechanical problem of the rotator cuff rubbing off the acromion bone and ligament on abduction but it is probably more complex than this. With the normal aging process there is breakdown of the fibres of the cuff. There is degeneration of the tendons and this sets up a repair / breakdown cycle. Pain chemicals are also involved.

If the pain persists for 2 months or so it will be worthwhile getting a MRI scan to assess the situation. The MRI will show the condition of the rotator cuff tendons and tell if there is an actual tear in the tendon. This is commonly in the anterior part of the supraspinatus tendon. It can occur with the normal aging process and can also be helped on its way by a fall which will cause a sudden failure of the tendon.
A tear of the rotator cuff may be a common finding in MRI of the shoulder and is seen in 50% of patients aged 60 years. If it is associated with pain I feel that a rotator cuff repair is a good operation for pain relief. In over 80% of cases the pain in the shoulder caused by a rotator cuff tear can be relieved by rotator cuff repair.

If there is no rotator cuff tear then there are simpler options available. Typical impingement pain may be a sign of a failing tendon that will go on to tear. An injection of steroid in the sub acromial space is certainly worth a try and can have a dramatic effect in about 50% of patients. A second injection can be used if the first one had a good effect. There are concerns about injecting of steroids. My opinion is that there is no hard evidence on how many injections can be given. I would usually stop at 2 and then move on to another treatment option but if the patient really did not want to go on to surgery then there is no reason not to have 5 or 6 injections or more. I am reluctant to give steroid injections to people who are involved in heavy work as I have seen that with the pain relief from the injections patients can go on to rupture their tendons from aggressive manual work. However if I have discussed this possible complication and the patient is going to take it easy I see no reason not to use this useful treatment.

For those that do not improve with injections then surgery to trim the acromion and decompress the sub acromial space is a good option. I find the pain relief after this procedure to be somewhat variable and may be not as good as in rotator cuff tears strangely. Some patients get a dramatic improvement and some others continue having pain. However it is certainly worthwhile persevering with rehab and giving the shoulder at least a year to settle after this surgery.

Rotator cuff surgery and sub acromial space surgery can often be combined with resection of the acromio clavicular joint. This joint when arthritic causes pain around the joint itself and also to the side of the neck. It can also cause impingement type pain. It can be resected arthroscopically by removing 1cm of the clavicle. The space then fills up with scar tissue and this prevents the arthritic bones from rubbing together.

A frozen shoulder is just that and I prefer this term to adhesive capsulitis as I am not sure if there is an inflammatory process involved. Usually for no reason the capsule of the shoulder joint becomes fibrotic, thick and stiff. The typical shoulder is frozen and there is very little movement with a solid end feel and no give in it. The patient could wait 1 to 2 years for it to thaw out or have arthroscopic surgery. I prefer to release the capsule arthroscopically as I believe that this cuts and releases the thickened capsule. With a manipulation, I see with the arthroscope that the capsule does not tear but it pulls the labrum with some bone from the glenoid off the glenoid itself and this is how movement is achieved. It is for this reason I prefer to see that it is the actual capsule that is cut by doing the procedure arthroscopically.
There may not be a dramatic improvement in movement but it starts the process of rehabilitation. Gradually the pain levels decrease and the movement increases. I find arthroscopic capsular release a good treatment option in a frozen shoulder.

Shoulder pain is usually caused by rotator cuff problems, acromioclavicular osteoarthritis and a frozen shoulder in middle aged patients.

In my next blog I will discuss shoulder problems in the younger age groups where there is a somewhat different spectrum of pathologies.

High Performance Sports Value and Funding

Olympics 2012

With the Olympics 2012 over for nearly 2 weeks Ireland has settled back to normal very quickly. I wonder has the euphoria totally dissipated. It is expected that those with a casual interest in sport will settle down very quickly and move on to the next event. But what are the lasting implications of Ireland’s participation?

Do we as a country have to decide what level we wish to participate in the Olympics at?
If it is possible to decide on that then we can decide on what funding is needed to achieve our aims because the Olympics has taught us if we needed to be taught that success requires investment.
The British cycling team are to be admired for setting out their stall, committing to the plan and bringing home the medals. None of this could be done without the massive funding they got. Still their achievements are magnificent.
The Irish Boxers success is a tribute to the clubs that organise boxing, train youngsters and bring them to national standard. The next step requires serious funding for the high performance team. We have all enjoyed their fantastic success and hope that the money can be found to continue it.
OK money is tight and it is worthwhile spending money on high performance in sport. The evidence of increased participation in sport and the trickle down effect is poor. What can’t be quantified is the feel good effect in the general population and the national pride generated by success.
The country needs to continue to invest in top level sport. This needs to be targeted to sports where we have a realistic chance of success and sports with some general appeal.
Sports organisations and individuals can tap in to the feel good factor by offering something to companies in the way of sponsorship deals. This is something that has a lot more to offer. Sports people need to be innovative in seeking sponsorship from small businesses that now may look favourably on small, niche deals. The private sector can and is willing to help high performance sport in Ireland.

Icing, cryotherapy and all that

I don’t know if icing is any good for injuries really. Having seen thousands of patients recover from knee surgery I can’t say that icing makes any difference. This goes against the accepted treatment and scientific studies to prove otherwise but I would not get too worried if you are not applying ice to your injury or your knee after surgery.

In fact you are probably saving yourself the hassle.

How cold does the ice need to be?

Can I put it against my skin?

How long do I apply it for?

You could save yourself all this and just not bother applying ice at all as for me it is not really the killer application.

What I do like is elevation. Decrease the swelling in the knee by increasing venous return and especially by not allowing that nasty bruising to go down the front of the shin bone after ACL surgery. This is really sore. Then it tracks around to the back and in to the calf and you are off to the hospital for a DVT scan.

Elevate your leg 2 feet higher than your head when at rest for the first week after anterior cruciate ligament surgery and by and large you will avoid all this trouble.

If you want to slap a bit of ice on as well for 10 or 15 minutes fine but don’t beat yourself up if this is too much trouble as it really does not make any difference.

I also think that cryo chambers are a waste of money in treating any injury. You know the ones where you go in to the freezer at -110 degrees C. I can’t find any decent scientific study to show that they have any influence on healing of sports injuries. Fine if individuals want to waste their money on them but people who give money to sports clubs should be careful that their money is not wasted on these treatments.

Another treatment that you need to think about is the non steroidal anti inflammatory tablet. To some people the goal of all treatment is to stop inflammation. But remember there is no healing without inflammation. A natural process that has evolved over millions of years must be stopped at all costs by the small brown tablets according to some therapists.

So start thinking of inflammation as a good thing and remember that it is necessary for the healing of your injury and surgery. You might want to control it a little but not turn it off altogether.

Cartilage Repair

Cartilage Repair – What is the state of play

Can cartilage be regrown?
The answer is not really or kind of.
So what is the best method to repair an articular cartilage lesion of the medial femoral condyle in a 25 year old footballer?
The answer to this is very simple. I don’t know.

So what kind of information can help in the management process. Let’s say that there is a defect on the medial femoral condyle on the MRI. It appears to be full thickness and may be 2cm in diameter. Given the limitations of MRI especially with 1.5 tesla scanners as opposed to 3 tesla machines it is difficult to advise a patient pre operatively on what is best.

Microfracture is one option where the diseased cartilage is removed with mechanical shavers and curettes and then the base is microfractured or peppered with small holes to release bone marrow stem cells which will go on to cover the defect with fibrocartilage rather than the normal hyaline cartilage. This is a reasonable treatment option even though the results may deteriorate after 2 years. Defects that are larger than 2cm2 are considered beyond the range for microfracture but these lesions are quite small and I think this technique can work with lesions of 2cm in diameter.

Lots of surgeons have moved on from this and have tried to get hyaline cartilage to grow rather than fibrocartilage. ACI autologous chondrocyte implantation is where cartilage is taken from the patient at the first operation. Then this tissue is sent to a lab where cartilage cells are grown from it. Then at a second operation these cells are implanted under a covering of periosteum which has been sutured over the defect.

The technique has been further improved so that now the cartilage cells that are grown in the lab are seeded on a membrane and then implanted in the patient. This is the MACI matrix autologous chondrocyte implantation technique.

So why don’t all patients with cartilage defects get a MACI done?

Well the technique has not been completely shown to grow normal hyaline cartilage.
It is very expensive to grow these cartilage cells in the lab.
It takes 2 operations. 1 to harvest the cartilage and another to implant them after they are grown.
The patient needs to be non weight bearing for 3 months and is off sport from 9 to 12 months.

This is not an exhaustive list of options. What about bovine scaffolds which fill the defect and then your own cartilage grows in to the scaffold and you have new hyaline cartilage grown back. Sounds great. We await the research proof on this one.

So what might be a reasonable, middle of the road, not very expensive, not too much hassle operation that has OK results.

You could do worse than try a microfracture, resect the diseased cartilage back to healthy tissue sharply with a curette, remove some of the hard surface bone, put holes in the defect through to the bone marrow but not too deep, put the patient on a continuous passive motion machine for 2 hours a day, stay 20% partially weight bearing for 6 weeks on crutches, do all the rehab, return to sport after 3 to 6 months and hope for the best.

And you could also inject the patient every week for 3 weeks with platelet rich plasma after the microfracture operation. This might be the killer app that pushes microfracture to the front of the peloton again. The platelet growth factors have been shown to enhance the growth of cartilage in the defect. The regenerated cartilage is somewhere between fibro and hyaline cartilage which is an improvement.

Now all you have to do is work out which PRP system is the best for this procedure.
Get back to me when you have that figured out.

15 Year Follow Up of Anterior Cruciate Ligament surgery

15 Year outcomes in Anterior Cruciate Ligament reconstructed patients

Leo Pinczewski’s study in the January 2011 edition of the AJSM has some interesting information.

In his article he followed 90 isolated ACL reconstructed patients over 15 years. 24% had a tear of the contra lateral ACL during that time and 8% ruptured their graft.
A vertically placed graft had a 10 times greater chance of an ACL graft rupture.
This is good news because in the last 5 years there has been a change in surgical technique where now surgeons are drilling the femoral tunnel through the medial portal so that the tunnel is more lateral than vertical. It is likely that this change in technique is resulting in fewer graft ruptures.

51% of patients had x-ray evidence of osteoarthritis at 15 years. The study showed
that the incidence of radiographic OA is lower in patients treated with ACL reconstruction compared with previous reports of patients with nonoperative treatment of ACL deficiency.

Younger patients are obviously more likely to have further trouble as they are more likely to continue to play at a higher level for longer. Patients did better after lateral meniscectomy compared with medial meniscectomy, with more patients progressing to OA after medial meniscectomy. Therefore, the effect of a less than one-third lateral meniscectomy on long-term functional and radiographic outcome is most likely minimal.
Of the 7 patients with meniscal repairs, only 1 patient who had medial meniscal repair required later meniscectomy, indicating that the other 6 patients had successful meniscal repair and were able to save their menisci.

All this is not bad news for this group of patients. However this represents only 90 of the 333 ACL reconstructions performed by Leo Pinczewski between January 1993 and April 1994. Exclusion criteria included any associated ligament injury requiring surgery, evidence of chondral damage or degeneration, previous meniscectomy or meniscal injury requiring
more than one-third meniscectomy at the time of reconstruction, abnormal radiograph results, abnormal contra lateral knee, patients seeking compensation for their injuries, and patients who did not wish to participate in a research study. Therefore, the study group consisted of
90 patients with an essentially isolated ACL injury.

To give a patient information before surgery I would like to know how the other 2/3 of patients do.

How does a total / near total meniscectomy affect outcome?

How does chondral damage affect outcome?

ACL LARS Augmentation Device

Another ACL graft option

Artificial ligaments in anterior cruciate ligament have had a bad reputation for a long time. So much so that they have been almost totally dismissed as an option in the USA and Europe. No reports at international meetings or in journals report on their outcomes. Until now that is and the April 2010 edition of the Arthroscopy journal.

A Chinese group Kai Gao et al report a multicentre 3 to 5 year follow up of ACL reconstruction using the Ligament Advanced Reinforcement System. LARS artificial ligament is a biomimic scaffold of artificial ligament made of polyester (polyethylene terephthalate [PET]) fibres. The intra-articular portion of LARS artificial ligament is composed of longitudinal external rotation fibres, and the left knee and right knee are separately designed, as clockwise or counter clockwise, respectively.

The graft is used as a scaffold when a stump of the torn ACL is present. The graft is placed through the retained stump. The study showed that LARS artificial ligament as a nondegradable scaffold in vivo could induce the growth of autologous collagen tissue and neoligament formation, which would increase the strength of LARS artificial ligament, avoid the abrasion of ligament fibres, and extend the longevity of the ligament. Basically a neoligament grows from the stump to surround the artificial graft.

This is not a controlled clinical trial. It is a therapeutic case series with a level 4 Level of Evidence. The results are similar to other case series using standard techniques. The femoral tunnel was drilled through the tibial tunnel unlike present techniques where the femoral tunnel is drilled through the anteromedial portal. There is not enough evidence in this article to change clinical practice.

Nevertheless it is an interesting study which should stimulate surgeons to have a second look at augmentation devices and see if they have a role. The obvious major advantage is they would avoid the need to take a graft from the patient, shortening operating time and reducing morbidity.

It is always interesting when someone challenges the accepted doctrine.

ACL Reconstruction and Platelets Rich Plasma

Platelet Rich Plasma and ACL graft healing

This is an area that will receive a lot of attention in the Sports Medicine journals over the next 2 years. The exciting question is can Platelet Rich Plasma (PRP) enhance the healing of the anterior cruciate ligament graft?

If it can then the time to return to full sport could be shortened. At the moment I think that it is best to wait for 12 months before a full return to sport as this gives time for the graft to become more like a ligament. In fact there is evidence that it takes 2 years for this process to be complete. If PRP could reduce the time for ligamentisation to 3 months then this would be a great advance.

I believe that a lot of failures are caused by a return to sport when the graft is not fully integrated with the bony tunnels and has not developed a proper blood supply and so has not become a ligament. The graft ruptures as it has not been given the time to develop fully. Of course tunnel placement is of great importance but I would like to emphasis the importance of graft integration.

There is quite a way to go yet with PRP and ACL recon. With many different concentrations and systems of PRP and different ways they are used with ACL surgery it is very difficult to nail down what system is best. Some studies have shown a decrease in tunnel widening which I believe is a good thing. The South American experience with PRP and ACL reconstruction has been led by Radice et al. in Chile. The authors found that the time to complete homogeneity of the ACL graft on MRI was 177 days for the group with surgery plus PRP, whereas the group with surgery alone required 369 days to acquire a matured graft. Moreover, when the subgroup of BTB autograft was analyzed, the maturation time in the PRP group was 109 days versus 363 days. In light of these results, Radice et al. concluded that the use of PRP accelerates graft maturation by half of the expected time, with an additional reduction in maturation time from 12 months to 3.6 months in the BTB graft and PRP group. These results are especially significant in light of the accelerated recovery time desired in sports medicine.

This is exciting stuff. It is probably the most promising advance in ACL reconstructive surgery in the last 10 years. Together with double bundle grafts this is where the future of reconstructive ACL surgery is going. First there was anatomical positioning and now the use of biologics to speed up healing.  Let’s hope that the studies will prove that the hope is real.

Tendon Injuries

Chronic Tendon Injuries

The biggest change I have noticed in the treatment of chronic tendon injuries over the last 10 years is the understanding of the pathology involved. I am talking about rotator cuff tendon problems, tennis elbow, patellar tendinopathy and Achilles tendinopathy. Whereas in the past people believed that this was an inflammatory condition now it is proven that this is a disease caused by micro tearing. All tissues have their breaking point and when this is reached fibres will start to tear. For some of the fibres in the tendon this breaking point is reached sooner and so some of these fibres break down leading to micro tearing.

Waterford Tendon talk

The important point is that this injury does not produce an inflammatory reaction and without inflammation there is no healing response. Tendons have a poor blood supply and therefore their capacity to heal is poor. These injuries do not adequately heal because there is not a proper inflammatory response produced. It takes a bit of a leap to get away from the idea that these tissues are inflamed and need to be rested, cooled and anti-inflammatories should be taken to instead going for a supervised rehab programme with possible extracorporeal shock wave therapy and possible autologous platelet injections to promote the inflammatory response and healing.

Non steroidal anti inflammatory drugs are used to get rid of the dreaded inflammation that so many people are keen to treat. Instead people should start to see inflammation as the body’s reaction to injury and is essential to healing. Sometimes inflammation can get out of control and needs to be reduced but we should be careful not to be so fast to reach for the tablets. The same goes of course for the steroid injections.

Even surgery can be required to promote healing. All forms of treatment seek to produce more of a response from the body.

So the message in chronic tendon injury is that we need to help the body to heal itself. That means promoting the natural inflammatory response and getting a new mindset in thinking about these injuries.

Platelet Rich Plasma

Growth Factors

There has been a recent surge in interest in the use of growth factors to promote natural healing of bone and soft tissue injuries. A variety of products have been developed to help stimulate biologic factors and promote healing. Platelet rich plasma (PRP) has received a lot of publicity recently. Platelets contain proteins, cytokines and other biologic factors that promote healing. PRP is produced by centrifuging a sample of anti-coagulated blood taken from the patient. It therefore has a 3 to 5 fold increase in the concentration of growth factors. The PRP is then clotted before it is used. About 30 to 60mls of blood will produce 3 to 6mls of platelet aggregate.

Some patients will get an immediate inflammatory reaction to the injection with pain and swelling. Patients can use ice and elevation to control the pain. Non steroidal anti-inflammatory drugs are not given for 2 weeks after the injection as they reduce the effectiveness of the treatment. PRP depends on the inflammatory healing cascade.

The indications for treatment have not yet been clearly established. It is showing some good results in patellar tendinopathy, Achilles tendinopathy, tennis elbow and even acute muscle tears. The exact indications and the technique of injection have yet to be defined. It is however an exciting development where the patient’s own blood is used to treat the condition with no risk from drugs or outside agents. There is no doubt that it is in the field of biologics where the next developments in the treatment of orthopaedic injuries is happening. We have to be careful with any new treatment as there have been false dawns in the best. I am also a little wary of any treatment that is the cure-all for all diseases. However platelet rich plasma makes sound scientific sense, is a very safe procedure and appears to work. We await the specific double blind trials that will define its role.

Breandán Long

The cost of Arthroscopic Products

Are there engineers out there who can manufacture relatively simple arthroscopic surgery devices that are used on a single use or limited re-use basis?

A single use radiofrequency probe can cost €150 euro. These devices are used to ablate degenerative articular cartilage in joints. They may be used for only 30 seconds during an arthroscopic operation on the knee and then thrown out. The device itself appears to be a simple product that conducts electricity across its electrodes. I would expect if there was a similar device to be used in the home for any reason you would expect to pay between €5 and €15 for it. It might even be 50 cents such is the simplicity of it.

It is similar with arthroscopic shavers and burrs. They are used to remove cartilage, meniscal tissue and bone from joints. These can cost from €60 to €150 for a relatively simple metal and plastic device which you would expect to pay a few euros for if it was not used in an operation.

There are safety issues and standards to be achieved but nothing as onerous as with a drug.
These devices are not left in the body so they do not have the safety issues that implants have.
It is not that the quality of the product has to be extra, extra special or that the testing can be particularly difficult. I know that sterilising these products has to be of the very highest standard but this is well established in all areas of medical equipment. I can’t see how a medical device can justify such a mark up.

So where are the start-ups that will take this on? Is there a whole business waiting to be developed in providing high quality, reasonably priced arthroscopic medical devices. Most of these devices have little or no electronics and no micro circuitry. Can they be so difficult to manufacture?