ShoulderDoctor

WHERE ARE WE WITH ORTHOBIOLOGICS?

I read the paper above recently with interest - it feels like the world has developed quickly with respect to orthobiologics and it’s interesting to critically evaluate where we are.

The overall aim of each of the people designing these orthobiologics is to restore the original anatomy and biology and they are each trying to approach this in a different way.

The paper goes through different types of orthobiologics - PRP, stem cells, growth factors, scaffolds and amniotic tissue-based products - and reviews how much evidence there is to support their use.

In most cases the conclusion is either that there is no “standardised” preparation (did you know that PRP doesn’t come in a one-size-fits-all solution?) so clinical studies cannot compare like-for-like.

This is the brave new world of injectables - it is as much about what preparation you’re having injected as the efficacy of that particular injectable.

This is an important message for patients - as this technology advances we should work to maintain standards of care - it’s certainly worth a discussion to help make patients who might be interested in this type of treatment to make them more aware that not all injectables are the same, even if they have the same name.

What is your view on orthobiologics and which ones do you have experience of in your clinical experience? Please share below

CAN WE TALK ABOUT “ACCELERATED REHAB”?

This recent study is an interesting one. was the first to post it on my feed and I’ve only just had a chance to look at it in more detail.

It proposes that “accelerated rehab” yields no worse a retear rate than standard “conservative” rehab but when you read the full study it defines “conservative” rehab as complete immobilisation for six weeks.

I think it’s important to define terms and always read the full study.

When I read this I assumed it was talking about accelerated rehab as sling off in a couple of weeks and passive ROM from day one progressing quickly. Had I just read the headlines I would have thought “great! Let’s get everyone moving even more quickly!” but as it is my post op protocol would already fall within the definition of “accelerated” according to this study. I don’t know if anyone who proposes complete immobilisation for a period of six weeks…

It does raise the question of what everyone does post-op and I’d be interested to hear what protocol you use if you’re a therapist or if you’re a surgeon what you tell your patients to expect. Please share below what you do so we can discuss what “accelerated” really looks like nowadays 👇

STORY TIME

I had two patients recently who came back to see me after a course of physio. One told me that her physio “wasn’t working” and the other patient came back asking for an op for the same reason.

When faced with this scenario I always try to understand why the physio “hasn’t worked”. We may scan to rule out pathology which has developed or worsened; we always talk about patterns of behaviour in the patient and their lifestyle and we also discuss the physio, both the treatment and the relationship.

In the first instance the patient told me that the physio she was seeing had treated her but that she didn’t particularly have much rapport with him. She felt disengaged from the process - it took a while to get to this as the patient was hesitant to give “negative” feedback about a practitioner. We discussed that sometimes all it takes is someone you get on with and I suggested a change of physio. This patient is now seeing someone different and doing much better. The new physio has educated the patient on why they are doing what they are doing, the relevant anatomy and also worked on relieving the pain she was feeling with some manual therapy to enable her to make progress. Big win.

The second patient is also seeing a different physio - it’s always worth a fresh perspective before discussing surgery, especially when we have ruled out pathology which might be causing symptoms.

Rapport is important in all healthcare relationships. Patient engagement makes so much difference.

Have you experienced this in your practice? Please share your story below 👇

THIS WEEK IN CLINIC - “JUST A SOFT TISSUE INJURY”

I saw a patient this week who has sustained a classic boxing injury - he’d rolled his wrist over and ripped off the ligaments in his wrist.

A visit to A&E and an x-ray later he was told he hadn’t sustained a fracture and that it was purely soft tissue related.

Many patients leave reassured at this point and he came to see me because he and his physio were concerned he wasn’t getting better.

The key takeaway in this case is that it might well be “just a soft tissue injury” and for the majority of cases these resolve naturally over time, but if it isn’t getting better after a reasonable period, get it checked.

Have you had “just a soft tissue injury” and if so what was your experience? Please share below 👇

IS IBUPROFEN SAFE TO TAKE AFTER A ROTATOR CUFF REPAIR?

This is the second paper I’ve read recently which talks about NSAID use after rotator cuff repair, particularly in terms of outcomes, effect on healing and opioids.

The paper compares two cohorts of patients, both groups undergoing arthroscopic rotator cuff repair. One group was given opioids and Ibuprofen and the other group opiods and a placebo. The study found no significant difference in patient reported outcomes at 1 year post op and lower opioid usage in the group also given Ibuprofen (as you would expect as they have effectively two forms of pain relief rather than just one!).

This conclusion should of course come with a health warning that any medication should be approved by a medical professional - NSAIDs are not benign and patients should of course take into account comorbidoties and keep their treating healthcare professional updated on how much and how often they are taking painkillers. However it’s encouraging to see that OTC medication does as well long term in treating pain as opioids and without the risk of opioid dependency.

If you’re a healthcare professional what do you prescribe for pain relief? What are your thoughts on NSAIDs? Please share below 👇

SURGICAL TERMS - IT’S ALL GREEK TO ME

I’ve had a few patients who truly never understood terms discussed with them by other healthcare professionals so always believe in discussing surgical terms in particular in plain English.

However when sharing information between healthcare professionals we have to use the proper surgical terms and so it’s useful to look at the definition of these common terms (most are derived from Greek!) and actually when you know what they mean then the rest is usually self explanatory!

If you’re a patient what was your experience of discussing a surgical term? If you’re a healthcare professional what language do you use with patients? Please comment below 👇

IS IBUPROFEN SAFE TO TAKE AFTER A ROTATOR CUFF TEAR?

A patient’s experience of a rotator cuff tear is as much, I find, about the pain the feel before and immediately post-op as it is about function so in my practice we use a nerve block to make the patient comfortable and then prescribe pain relief post op. We try not to prescribe opioids where they can be avoided and to only prescribe a one-off short course if necessary. Patients are then reliant on over-the-counter medication such as Paracetamol and Ibuprofen.

Non-steroidal anti-inflammatory drugs (NSAIDS) are often maligned because of possible side effects, and in the context of post-op healing potential for slower healing, so I was interested to read this paper.

The paper compares two cohorts of patients, both groups undergoing arthroscopic rotator cuff repair. One group was given opioids and the other group Ibuprofen. The study found no significant difference in patient reported outcomes for pain, function and overall health at 1 and 2 years post-op.

This conclusion should of course come with a health warning that any medication should be approved by a medical professional - NSAIDs are not benign and patients should of course take into account comorbidoties and keep their treating healthcare professional updated on how much and how often they are taking painkillers. However it’s encouraging to see that OTC medication does as well long term in treating pain as opioids and without the risk of opioid dependency.

If you’re a healthcare professional what do you prescribe for pain relief? Please share below 👇

ALWAYS GET THE FINAL X-RAY

How do you know if a fracture has really healed if you don’t see this on x-ray?

This patient came to see me with pain and recently, his elbow had been starting to look a bit wonky and he had lost some movement.

We took an x-ray and found that the fracture had NEVER healed and had simply been held together with the screw which had eventually given way and broken, leading to the recent deformity.

The original fracture had been while this patient was in his teens. He’s now in his 30s. 😱

When he sustained the original fracture and subsequent fixation he was told “come back if there are any problems” but there was no final x-ray taken to check for radiological healing. In that context that screw did pretty well lasting as long as it did.

Much as clinical examination is an important part of medical practice there are some situations where an x-ray as well, is best practice. A picture is worth a thousand words, especially in fracture fixation.

Have you had a similar experience with a fracture? Please share below.

*Posted with thanks to this kind patient for his permission to share.

WOULD YOU INJECT A TEENAGER?

Last week in clinic I saw a now 18yo patient who told me she had had shoulder pain since the age of 13. She had received 4 steroid injections in total, two on either side of a subacromial decompression.

I was wearing a mask in clinic but despite that I think my facial expression was clearly visible.😶

I don’t yet have full details of why this patient had had the treatment she had, and will update here with the patient’s permission when we have more details but the immediate thoughts I had were:

- in the absence of trauma, a teenager should not have to be in pain for that long. A young person’s ability to heal is amazing and they will recover from most injuries much quicker than an adult patient. There are some conditions such as a traumatic shoulder dislocation where structural injuries might need surgery, but imbalance, dysfunction “strains” should settle with rest, advice, education and physical therapy.

- as I always say with injections, if it didn’t work the first time, why give it again?

- steroid injections can be useful but only if you are also doing something else, such as activity modification or physical therapy.

I’ve had a few consultations recently with teenagers and young adults and find that they should be treated just as an adult in terms of engaging them in their consultation and treatment. Explain what’s going on, the options open to them and the plan you’re working on with them and more often than not they will reach a good outcome.

Have you had any younger patients recently and what are your key learnings? Please comment below. 👇

WHAT COULD GO WRONG WITH AN INJECTION INTO THE ARM?

I’ll start by saying that I’ve now had two vaccinations and fully believe that if it is offered to you, you should take the vaccine. Most people suffer very few to no side effects and if, like me, you do experience some side effects these are usually transient and mild, especially compared to how badly you can suffer from COVID.

That said, I have had a few patients who have had longer-term shoulder-related symptoms - a rare but recognised condition known as a shoulder injury related to vaccine administration (SIRVA).

What can go wrong:

Too deep - it can hit the bone causing a bony reaction and quite intense pain, literally a bone ache radiating down the arm for a few hours.

If the injection is into the bursa this can cause bursitis, and I sometimes evolve into adhesive capsulitis.

Too shallow - this can result in a localised subcutaneous reaction, with thinning of the skin, puckering and localised pain and hypersensitivity. These changes can last for weeks.

Too low - the axillary nerve runs approximately 7-8cm below the tip of the shoulder and supplies the deltoid. An injection that causes injury to the nerve can result in weakness of the deltoid and therefore of the shoulder and numbness around the upper arm
Too high - the injection either hits the acromion with similar results to if it goes in too deep (hitting the humerus). Similarly too high an injection can cause the injection to be placed in the bursa, leading to a similar inflammatory reaction as if it is given too deep.

Infection: Although very rare (perhaps in the order of 1:5,000-1:10,000), an injection can sometimes cause an infection at the site of the injection.

The message is not to ignore or write off symptoms such as these following an injection. These types of complications are rare and easily treated.

If you’re a healthcare professional have you seen any of these cases in clinic recently? If you’ve had an injection did you suffer any of these symptoms? Please comment below 👇

HOW SOON AFTER VACCINATION CAN YOU HAVE SURGERY?

As the vaccine rollout in the UK continues more and more age groups are being offered the vaccine. The question of how soon after vaccination you can have non-urgent elective surgery is therefore highly topical.

The guidance from the Royal College of Surgeons is that you should wait for approximately one week for any symptoms of the vaccination to subside.

The guidance from many hospitals however is that you should wait for THREE WEEKS.

The rules are different if surgery is urgent and/or non-elective because the requirement for surgery has to be balanced against the risk of post-vaccination side effects.

It’s worth checking the circumstances around your particular case if you’re considering surgery, and always make the surgeon and pre-assessment team aware of your circumstances regarding vaccination, including if you’re booked in to have the vaccine post-surgery, so that they can guide you appropriately.

Have you recently had the vaccine? Are you concerned about surgery? Please comment below 👇

LIFE BEYOND 75

This recent study looks at whether a rotator cuff repair is a worthwhile endeavour for over 75s and concludes that it is worth operating for the potential improvement in quality of life.

I have a few thoughts on this:

1. Let’s start with “not all cuff tears need repair”. Certainly lots of over 75s will have asymptomatic rotator cuff tears and never know or need to do anything about it. This study looks at the symptomatic ones.

2. Let’s not write off the over 75s - sure there are other considerations as we age, but nowadays in many patients their quality of life is as good in their 70s as it was in their 50s. Many over 75 year olds make an effort to stay fit and active. If we are applauding these efforts at fitness we should also consider that these same fit over 75 year olds might benefit from an operation if they need one.

3. Consider any operation in the context of lifestyle. At least 50% of the recovery from a rotator cuff repair is about the rehab. Most over 75s I have treated arrive at the decision to surgery with much thought and so are motivated in their rehab (more, sometimes, than a younger patient who might take recovery for granted).

4. That’s in the last picture. She’s 83. Be like Jane.

TESTING, TESTING...

There’s been a lot of discussion over the years about “special” shoulder tests and their efficacy so I was interested to read this recent paper which looked at the predictability of shoulder tests when compared to MRI findings.

This paper found some merit in some of these tests - always reassuring to know that clinical testing isn’t just a pointless exercise, especially in primary care when you need to come up with a working diagnosis without the luxury of imaging.

I use tests but I find that the key is in what the patient tells you about their symptoms - the history. You can learn a lot from this information and then use tests and imaging to confirm your diagnosis.

How do you feel about “special tests”? Is your can empty or full 😁? Please comment below 👇

STEROID INJECTION RISKS AND COMPLICATIONS

One of the most commonly talked about treatments (I’ve had patients coming in and outright asking) for shoulder pain is a steroid injection. Love them or hate them, in the right circumstances they can greatly alleviate pain and help other modalities of treatment to work more effectively.

However they come with their own risks and complications - as I always say when talking about this topic - they are not benign.

In this post I’ve listed in the main risks and side effects. Some are more commonly known than others but when discussing risks and complications it’s important we talk about all of them, however rare they may be.

What’s your experience of steroid injections? Have you ever had one and how was it for you? Did your healthcare professional discuss risks and complications and give you time to think about it? Genuinely interested as attitudes to this can vary greatly from one practice to another, and between countries! Please comment below👇

HYDRODILATATION FOR FROZEN SHOULDER

Does a corticosteroid injection, physiotherapy or hydrodilatation provide the best method of treatment? This is a popular topic of debate among people who treat frozen shoulder and this paper suggests that hydrodilatation is the most effective form of treatment in the short term.

In my clinic we have been using hydrodilatation for years as an effective treatment for frozen shoulder (patients almost always come to me having had a course or physio first which for them hasn’t worked) - it’s relatively quick, non-invasive and gets great results. However I ALWAYS send patients for physical therapy after a hydrodilatation in order to ensure the effects of the treatment are optimised and the patient goes on to a full recovery.

I’m still regularly surprised by the number of patients with frozen shoulder who have heard/been told that it “will take a couple of years” from their frozen shoulder symptoms to resolve. This might be the case if they did nothing and waited for their frozen shoulder to “thaw out” but there’s no reason nowadays not to seek treatment.

If you’ve had frozen shoulder please share your experience below. If you’re a physical therapist what’s your treatment modality? Please share below 👇

LOCAL ANAESTHETIC + BLOCK = LESS POST-OP PAIN

I co-authored this paper (FULL PAPER AVAILABLE TO DOWNLOAD VIA LINK IN BIO FOR THE FIRST 50 DOWNLOADS) to put some science and measurement behind something I’ve known and used in my practice for a long time - that a combination of local anaesthetic and interscalene block leaves patients with less post-op pain, spent less time in recovery and were able to be discharged on the same day.

In my practice I try to look at the whole experience - pain relief is a large component of an operation so we try to make our patients as comfortable as possible. An interscalene nerve block is just like an epidural (except it numbs the shoulder and arm). Along with local anaesthetic it helps to smooth the pain curve such that patients can get some oral pain relief on board post-op before they start to feel uncomfortable. Psychologically this helps a lot in giving patients confidence about their post-op rehab.

If you’re a healthcare professional what is your experience of discussing anaesthesia with patients? In your experience what are patients concerned about? If you’ve had shoulder surgery did your surgeon discuss anaesthetic options with you? Please share your experience below 👇

WHAT TYPE OF SCAN?

Do you get requests from patients to send them for a scan? Which type is most appropriate?

The answers to these questions will be based on what you’re trying to establish, and frankly what the patient is comfortable with.

MRIs are probably the most versatile type of scans as they can show both bone abs soft tissue, however they’re not the best, for example, to use for fractures.

X-rays are cheap and useful for looking at fractures, and I will sometimes also augment with a CT scan to look at complex fractures as a template for surgery (to allow me to see where bony fragments are placed in 3D and plan surgery).

It’s also possible, of course to use more than one type of scan at the same time so, for example, if a patient is claustrophobic a good compromise might be to send them for an x-Ray and ultrasound scan instead.

Nowadays with diagnostic technology we should be able to diagnose, benchmark and plan treatment relatively easily without resorting to anything invasive - save the surgery only to fix something you cannot treat conservatively!

If you’re a healthcare professional what are the most common questions you get from patients about scans? How do you explain why you’re sending for one type of scan vs another - please comment below.

TYPES OF FRACTURE

Orthopaedic surgeons are great people to discuss fractures and we can definitely talk knowledgeably about them however some of the classification is often difficult for patients to understand.

This is a useful illustration for using with patients who might have suffered a fracture so that they can better conceputalise what is going on at their fracture site and why a particular form of fixation (or indeed none!) has been recommended.

If you’re a healthcare professional how do you discuss fractures and treatment options?

TYPES OF RC TEAR
I try my best to speak in plain English with my patients but sometimes we have to communicate things like tear configuration and/or go through scan findings together.
This helpful illustration by shows exactly what the different types of tear look like.
In my experience it’s most often partial tears that patients struggle to conceptualise, especially when we are discussing how physical therapy can help to heal these.
If you’re a therapist or a patient who has discussed the size or shape of a tear how easy was it for you to understand this and did it help you in your treatment plan?

ONE-STOP CLINIC

Twice a week I run a one-stop clinic with a consultant radiologist colleague. We’ve been running this for years but at the moment patients are particularly grateful not to have to travel to multiple appointments for scans and follow up appointments. The one-stop clinic does what it says on the tin - you turn up, are examined and scanned in the same appointment, we discuss the scan with you and you leave with a diagnosis and treatment plan which has been confirmed with imaging.

In these difficult times we are trying to do all we can to help patients manage the number of in-person appointments they have to attend.

If you’re a health professional have you implemented ways to help patients which we could all learn from? Please share below 👇

RETURN TO EXERCISE POST-COVID

This flowchart and article was published in the BMJ. It might be common sense advice but serves as a useful reminder for us and our patients to take it easy post-COVID.
The article advises that some patients who might have experienced cardiac symptoms such as breathlessness might warrant further investigation however it can be difficult to distinguish what might be a cardiac symptom from a purely respiratory one - if you have a cough does that make you out of breath or might you have an underlying cardiac issue?

In the current healthcare environment where resources are stretched and the guidance is to stay at home it might be difficult to get a cardiac review quickly.

My take on this, therefore is to err on the side of caution for everyone who is post-COVID. Now, more than ever, it’s time to be kind to ourselves and our bodies. A phased return to activity might, for example, be walking before you try running again even though it’s frustrating. Give it the time you need to get back to full health.

I previously trained 3-4 times per week but at the moment I’m down to once a week and lighter activity. I’ve found breaking down the component of my life workout and adding them back one by one has helped.

As with all internet advice, it’s best to speak to your doctor or another medical professional or you are at all concerned.

If you’ve had COVID what has been your experience of post-COVID return to exercise?

HOW MUCH PAIN WILL I BE IN?
One of the questions patients often have (but I wonder how many actually ask!) is how much pain they will be in post op.
Pain is of course subjective but having an operation is bound to be painful - not only have you had an incision, in most cases you have had invasive surgery. You should expect for it to be painful.
However, the job of a good surgical team is to minimise your post op pain and certainly complete pain relief in the immediate post op period is our aim.
This study also looks at the factors predicting post op pain (level and frequency) and finds that the following have some correlation with how much pain you will likely experience at 6 weeks post op:
- Preoperative pain
- Tear size
- Younger age
- Female s*x and
- Work-related injuries
If you’ve had surgery what was your experience? Please comment below 👇

IRREPARABLE CUFF TEAR OPTIONS
This recent study is an interesting one - the balloon spacer was first introduced 7-8 years ago but the initial successful trials could never be replicated and my personal experience was that it didn’t really work at the time.
Since then the implantation technique has been refined, allowing near immediate and perhaps now improved physical therapy programmes to help make it more effective.
The point of this technique is to return the shoulder biomechanics which may have failed due to a (usually) long-standing, irreparable cuff. A big part of this is physical therapy as muscle function in the area is key. This is done by implanting a balloon spacer - a relatively small operation.
Given that this might help (usually older) patients avoid a bigger operation it’s worth considering and discussing with patients as a treatment option.
Bottom line is there are lots of options available to return the shoulder to full function even if you have an “irreparable” cuff tear.
If you’re a therapist have you treated a patient with one of these and what was your experience? If you’re a patient who has had a ballon spacer implanted please share your experience below 👇