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9 posts from February 2012

February 29, 2012

Shoulder labrum tears, what is the deal with these?

The shoulder is an amazing joint with an remarkable range of motion.  

We pay a price for that range of motion.  The shoulder is inherently unstable.  The ball and socket joint is comprised of a large ball resting on a flat and shallow joint or a dish.  The dish itself has a rim around it called a labrum. The labrum itself acts to deepen the socket and make it inherently more stable. 

Tears can occur in the labrum can cause a variety of symptoms.  The shoulder can have painful clicks and feel unstable.  The shoulder can have quite a bit of pain when reaching overhead. 

Labral tears are tough to diagnose.  We do get some clues from the physical exam. Many MRIs do not show the labral tears.  Many times special dye needs to be injected into the joint to help define the tear.  Many times it is not truly diagnosed until surgery.

The crazy thing is that WE DO NOT KNOW THE NATURAL HISTORY OF LABRAL TEARS.  Yes we have no idea which ones will get better and which will not.  SO THE UNDERLYING MESSAGE IS LABRAL TEARS DO NOT EQUAL SURGERY.  What you need is a good therapy regimen.  

Good luck.  These are a bit of a bugger and take some time to get better.

February 28, 2012

My favorite shoulder pain testimonial

Yes, I do run this shoulder pain blog site that I do try to run as unbiased as possible, but (full-disclosure) I do run a company that sells Rotatoreliever.  The rotatoreliever is the best, most effective, noninvasive and guaranteed shoulder pain relief product on the market.

We do believe in research and have published amazing results with our product.  Research is fun, but getting testimonials is funner. 

We have enjoyed some amazing testimonials regarding customers that have enjoyed relief of chronic pain. Certainly the athletes that we have returned to high level competition have been great, but getting the older folks better is even more gratifying.  

The problem older patients face is that, for some, the medical profession has given up on their shoulder pain.  These people frequently have multiple medical problems, they have already failed physical therapy and even my aggressive orthopedic colleagues won't touch them with a surgeons knife.

So of the hundreds of testimonials that I have gotten, my favorite is Mrs. Pruitt of Muskegon Michigan. I received the testimonial on very thin paper about 6 by 8 inches.  The letter was typed.  My only truly typewritten communication in about 15 years.  

Mrs. Pruitt could not reach up to her cupboards.  The stools were not high enough and she could not get her arms above the level of her shoulders.  She had scheduled a contractor to come in to lower the cupboards to counter height throughout the kitchen.  After using our product for 10 days she was able to cancel the contractor.

Hey, I am a practical man offering a practical solution.  This testimonial resonated.  

Thanks for reading,

Dr. C 

February 24, 2012

We lost Tom to golf because of his shoulder, a tale of woe

 

“We’ve lost Tom to golf.”  This is what I heard as I was warming up for my weekly doubles league Tuesday night match.  “Why” I asked, I had heard that his recovery from rotator cuff surgery was going well.  His partner enlightened me.  “His doc told him ‘No overhead sports’ and Tom said ‘the thought of going through another shoulder surgery induces immediate vomiting’”.  Wow this was tough on the league.  We had been scraping the ‘subs’ to keep our full contingent over the last 4 months.  Tom was our most gifted player and pretty much elevated the play of the whole group.  I felt pangs of separation similar to when my best friend moved to Mexico in the second grade.  I knew I would see Tom again, but just like my buddy Karl in 1977, it just would not be the same. We would not have the common ground, common language, and common experience that tied us together.

Middle aged tennis players are a hardy bunch.   We pride ourselves on not verbalizing our complaints.  The evidence of our loss of elasticity, however, is evident in the braces, tape and prolonged warm-ups we now require.  Our ice machine in the tennis house is like an office water cooler, we fill our bags after the match and share a beer with the healing cold draped over our shoulders and knees.  We made it.  We had negotiated a fragile truce with our bodies that allowed our continued participation in a vigorous, competitive, supposedly livelong sport.  “What the hell happened to Tom?”

Well, doggonit, I was going to find out.  Tom was our leader.  Was his fate a premonition?  Were we all destined to the green acreage of the sedate golf course?  Did I need to worry about a chippy 7-iron vs. a lob wedge around the green?  Should I renew my Golf Digest subscription that I triumphantly cancelled in 1998?

I set about answering these questions by going to the source first.  I interviewed Tom. 

Lunch was away from the tennis club.  We were in the first floor restaurant of his office building.  Tom is a successful acountant, at least his large firm bears his name.  He looked sharp in his grey suit, in spite of a gargantuan shoulder sling that held his arm contorted and away from his torso.  I awkwardly shook his left hand.

Turns out there was no aha moment for Tom and his shoulder pain.  Fifteen years of progressive shoulder pain.  No injury, no fall, no “popping” sound heralded this fate.  The pain started with an ache after his toughest matches.  Being the fighter that he is, his self therapy was hitting the gym, weight training.  Over months that served only to extend his pain into the night.  Tom, the prudent accountant, consulted his doctor.  Impingement syndrome was the diagnosis.  He was assured that a round of physical therapy would have pain free in no time.

The physical therapy worked.  He felt so good he added a singles league on Thursdays.   He diligently performed the home exercises and did well…for six months.  When the pain came back with a vengeance his physician ordered an MRI.  “Tom, you have a tear in your rotator cuff” was the assessment upon review of the films. 

He was crestfallen.  “Tears need to be stitched together, right?” he asked.  “Not always” was the answer “Let’s consult an orthopedic surgeon”.  The surgeon prescribed another round of physical therapy.  This time the PT only gave him 2 months of relief.  Tom was on his way to the operating room.

So, I had my tennis buddy’s story of woe, time to consult some other experts. 

Todd Ellenbacher, a physiotherapist in Scottsdale, Arizona and the director of sports medicine for the ATP world, explained “Tennis is pretty hard on the shoulder.”  The problem is a basic one of muscle imbalance in the shoulder joint.  The critical four muscles of the rotator cuff are relatively weak compared to the larger, possibly more glamorous muscles of the shoulder.  The pectoralis, deltoid, and trapezius muscles of the shoulder get stronger with tennis.  The rotator cuff muscles do not.  Turns out that this imbalance can cause major problems. 

Kevin Westrick, a kinesiologist, with Creekside Physical Therapy, has spent 20 years treating shoulder injuries.  He describes the rotator cuff as the muscles that keep the shoulder within the joint.  When the rotator cuff muscles weaken the top of the arm bone tends to squeeze upward, damaging the critical muscles of the rotator cuff.  This process first leads to pain and inflammation.  The inflamed muscles are particularly susceptible to tearing. 

The tennis serve puts tremendous pressure on the shoulder joint.  A 2009 review article in Sports Medicine reports that forces equivalent to 120% of a players body weight are transmitted through the shoulder with each serve.  During this the rotator cuff has to act as “the brakes of the shoulder,” said Paul Borsa, an associate professor of applied physiology and kinesiology at the University of Florida who has studied shoulder injuries. 

Like many in the population at large, tennis players frequently have weak rotator cuff muscles. “Playing tennis builds up the muscles in the front of the shoulder, but it doesn’t build up those in the back very much,” states Mr. Ellenbacher.  The muscle imbalances lead ultimately, to an extremely common type of injury that Mr. Ellenbacher terms “Toyota shoulder-all acceleration and no brakes.”

Tom, Tom, Tom where did you go so wrong?  All he had to do was strengthen the rotator cuff.  Why was this such a challenge?  Mr. Westrick explains the challenges he has encountered over his 20 years of treating the condition. “The shoulder is a beautiful joint-270 degrees of motion in multiple planes.  Isolating the four critical muscles in this sea of movement is not all that easy.”  He describes patients using a common technique of band exercises with faulty technique.  He notes that 17 muscles are attached to the scapula, a bone in the back of the shoulder.  “I have to be standing over the patient, almost constantly, to make sure they are doing it correctly.”

My shoulder is starting to hurt just listening to this.  My insurance has not agreed to my proposal of personal trainer, therapist and technique coach.  I did not even include my hopes of sports psychologist to blossom my budding career.

The current antidotes to this are anti-inflammatory medications, physical therapy and surgery.  None of these sound all that hopeful.  A recent review article out of Australia recently noted that 47% of tennis players suffer shoulder pain.  They glumly conclude that there is no definitive therapy that has been sufficiently proven to address the problem. 

A bit of direction comes from Mr. Ellenbacher “You do not need to use a lot of resistance.  You want to build endurance more than power.”  Mr. Westrick cites research recently published in the Journal of Sports Medicine.  “Nighttime positioning is an important piece of the puzzle.  Many people with the muscle imbalance are hurting their shoulders with sleep position.”

Get the rotator cuff stronger and sleep in the correct position.  OK, how do we do this?  Mr. Westrick endorses a specific product.  “The Rotatoreliever is the one product that I can confidently give to the patient knowing that it is easy to use at home and remarkably effective.” This product apparently has a nighttime component and a unique exercise for daytime.  He states further “this product is getting a lot of attention with my physician colleagues.”

What about the surgery?  There have been numerous advances with surgical techniques that are well publicized.  All of the surgeries now are done laparoscopically ie-small incisions.  I asked Tom to comment.  “The surgery has been tough.  I feel like I am out of commission for 6 months, but I can already tell the pain is decreased,” he says with a weak smile.

Tom ads, “don’t worry about me, I was a 6-handicap before I got cut.”  Superior athletes and their smug confidence will forever vex me.  Good riddance from our tennis house.  Maybe I can finally finish better than fourth in our doubles league.

 

 

 

 

 

 

February 22, 2012

Shoulder pain can kill you, seriously read this

NEAR DEATH BY SHOULDER not written by Agatha Christie

 

“How the hell did this happen exactly!” my brain screamed.  Anger initially prevailed over panic as my kayak wedged upside between 2 rocks and underneath a 400gallon per second rush of class 4 whitewater.  “Goddamn shoulder.  This right shoulder has been screwing me for months and now it is going to kill me.” 

The moment of truth had passed about 20 seconds earlier.  We were running the Green River outside of Seattle.  This was my fourth trip through this beautiful piece of the Cascades.  My body had become a fairly finely crafted kayaking machine over the previous 8 years of kayaking the northwest.  I was ready for the Green.  There was no planning.  Like the steep part of the mogul run, getting through the Green River down to the sedate outskirts of our fair city required rhythm and skill.  I had neither of these skills in any other sport in which I toiled over my previous 28 years.  I contend that I had become, dare I say, graceful in my custom made kayak of late.  I had done a short stretch of class 5 in Oregon just a week ago.  I was ready for this.  At the critical moment my own anatomy betrayed me.  On my big reach, the stroke I needed to have, I could not get my paddle beyond a small boulder.

At least I was conscious, I thought.  I have a fighting chance here.  My anger was slipping quickly into panic.  Think, please think, Mike.  How are you going to get out of this mess?  I suppressed the notion of my questionable recreational sport of choice.  I could have likely gotten a golf game on this beautiful Saturday with my dad and brothers.  OK, more of this torrent of water is hitting the front of upside down kayak.  I had violently wrenched my body to the side three times without a budge.  I knew I was losing strength.  Could my adrenaline save me?  I bent forward until my helmet hit the kayak and threw myself backward with all my might. 

Daylight and air.  My last desperate maneuver worked.  I was thrown back into the toilet bowl vortex, never so happy to going backwards and out of control.

What the hell happened?  My analytical, possibly obsessive compulsive nature, did not relax upon my second lease on life.  I was happy to be alive, but I was disgusted at my own, I felt premature, brush with death.  Why did my shoulder betray me?

“I make a great living off shoulder pain,” the University of Washington orthopedic surgeon shared with me 2 days hence.  “Modern day plague” he contended as he jammed his finger into fire-poker tender area of my right shoulder.  “Did you know that 60% of 60 year olds have a rotator cuff tear?  Can you say job security?” he smugly asked. 

I am a free-lance writer and job security was not in my vocabulary.  I reluctantly came to appreciate the steroid injection he placed deep within my shoulder, but I needed to know more.  Why did my shoulder fail?

“The shoulder is a beautiful joint, with a 270 degree range of motion.  The most mobile joint in the body,” explained Dr. Michael Carroll, a family doctor in Traverse City Michigan who claims to be changing the way the world thinks about shoulder pain. “The problem with such a complex joint is that it requires so many parts to be working in the correct manner, sequence, and balance.  When it goes bad it tends to stay bad unless you restore proper function.” 

OK so how am I going to get my shoulder better?

The current antidotes to this are anti-inflammatory medications, physical therapy and surgery.  None of these sound all that hopeful.  A recent review article out of the University of Pittsburgh recently noted that 47% of kayakers suffer shoulder pain.  They glumly conclude that there is no definitive therapy that has been sufficiently proven to address the problem. 

A bit of direction comes from Dr. Carroll “You do not need to use a lot of resistance.  You want to build endurance more than power.”  Mr. Westrick, a kinesiologist with 20 year history of treating shoulder pain, cites research recently published in the Journal of Sports Medicine.  “Nighttime positioning is an important piece of the puzzle.  Many people with the muscle imbalance are hurting their shoulders with sleep position.”

Get the rotator cuff stronger and sleep in the correct position.  OK, how do we do this?  Mr. Westrick endorses a specific product.  “The Rotatoreliever is the one product that I can confidently give to the patient knowing that it is easy to use at home and remarkably effective.” This product apparently has a nighttime component and a unique exercise for daytime.  He states further “this product is getting a lot of attention with my physician colleagues.”

What about the surgery?  There have been numerous advances with surgical techniques that are well publicized, but the best case scenario I can find for recovery to kayaking is 4 months and most report 8 months. 

I am sitting here pondering the terror of my recent near death experience.  My shoulder still hurts when I reach, but the water calls.  I will do my own therapy: scenic flat water.   

 

 

February 21, 2012

Adding muscle to the shoulder and everywhere else

So, first of all if you want a strong shoulder then you have to have a strong base.  The base of the shoulder is the rotator cuff.  I see so many athletes and nonathletes that have muscle imbalance of the shoulder.  Their pecs, traps and deltoid are plenty strong, but they have lost balance.  The rotator cuff whose job it is to keep the ball of the arm bone situated in the joint is not strong enough to fulfill the mission.  There it is, I said it. That is why 40 million americans have shoulder pain.  

I my opinion there are 2 ways to strengthen the shoulder.  Either jump rope with regularity about 10 minutes 4 times a week, or use my product called the Rotatoreliever 4 minutes a day everyday.  My product also has a nighttime component, but you only need that if you are already having shoulder pain.

Telling most people to jump rope is like telling them to chew on glass.  They look at me like I am nuts.  OK those people can just buy my product, no problem.  

I have an admission to make.  For years I thought protein powders were bunk.  Just eat right and work out and you will do fine.  But alas, the research has finally convinced me that I have erred in my ways.  Protein powders are important, particularly for old guys like me.  At 43 I am not that good at building muscle.  My body needs as much help as it can get.   The old guys and girls are the ones that need protein powder the most.  

Consider the following.  Skeletal muscle represent 50-75% of all body proteins and approximatlely 40% of total body weight.  In addition to sheer volume, muscle possesses numerous vitral functions such as for generation, temperature regulation, energy metablolism, amino acid reserves, immune function. In addition, the loss of muscle mass with advancing age (sarcopenia) is quickly becoming recognized as a major health concern as it has been linked to increas disbilitry, loss of independence, and decreased life expectancy.  

RESISTANCE EXERCISE AND THE REGULATION OF MUSCLE PROTEIN SYNTHESIS (mps).

Resistance exercise stimulates and increase in the rate of muslce protein synthesis.  The increase in MPS  occurs within ght first hour after exercise and can persist for 48 hours.  

AEROBIC EXERCISE AND TEH REGULATION OF MUSCLE PROTEIN SYNTHESIS

Acute aerobic exercise stimulates MPS in the the fasted and sed states, while chronic aerobic exercise siims to elicit an increase in MPS at rest. Aerobic exercise primarily increases the mitochondrial protein synthesis (making the muscles you have stronger and more efficient) instead of myofibrillar protein synthesis (muscle mass). 

AGING AND RESISTANCE TRAINING

Muscle loss observed in aging seem related to not building muscle in response to resistance training like the younger. 

ESSENTIAL AMINO ACIDS (EAA) AND THE REGULATION OF THE MPS

Amino acids have been shown to stimulate a muscle protein anabolic respone.  The stimulation of MPS last 1-2 hours after EAA ingestion.  Of the EAA luecine has received considerable attention becouse of its ability to independently stimulate MPS.  

AGING AND EAAS

The devil is in the details.  MPS is stimulated in older adults after ingestion of leucine-enriched supplement (6.7 g of EAA, 41% leucine), but with EAA (6.7 g of EAA, 26% leucine) MPS was not stimulated.  In young people it did not matter.  So the older folks appear to need at least 41% leucine in their supplements.  Further, small meals of protein (113g of lean beef) stimulated MPS and large meals of protein (340g of lean beef) did not.  This suggests that saving your protein intake for one meal a day is not a good idea.  

Also ingestion of 6 g of EAAon hour after resistance exercise dramtically increased MPS.  Some studies have shown that ingestion of 20g of protein after exercise results in similar stimulation of MPS.

CONCLUSION

Work out.  Eat protien or essential amino acid supplement (high in leucine) 1-2 hours before and 1 hour after resistance training.  

HOPE THIS HELPS

DR C

 

February 19, 2012

Male stinky crotch syndrome

Ok.  I am going to deviate from my typical subject matter of the painful shoulder.  I am after all a family doctor and I see all kinds of problems every day.  

Recently I have had a number of guys complain about the stinky crotch.  These patients note that no matter how often they shower and soap they get a gross smell from the netherworld of the crotch.  This disappoints for many reasons.  

These guys are not dumb.  They have already essentially eliminated jock itch or as we like to say in the medical world tinea crura.  They do not have a rash and there is no itch.  Often they have already tried antifungal powders to no avail.  

What is going on?  Gram negative bacteria.  Yes the bacteria that allows our digestive system to work and makes our farts smell is the culprit.  Why you ask does the soap not work?  Well, gram negatives are tough.  Some of them essentially develop a resistence to antibacterial soap.  

What is a man to do?  Throw those bacteria a curveball.  Get a stronger soap to use for a few days in a row when the smell starts to waft.  I recommend Hibiclens.  This is a medical grade soap and used to scrub areas before surgery.  Good stuff.  Use this for a few days and the smell should be gone.  Do not continually use it as you do not really want the little buggers getting used to that as well.  

Good luck, don't stink and you do not have to take 3 showers a day as some blogs have suggested. 

Dr. C

February 18, 2012

The Rotator cuff is 4 tendons, does it really need all that surgery?

People speak of the rotator cuff like it is a deep monster of the shoulder and when it rears its ugly head it needs to be beaten back with a surgeon's knife.  

The rotator cuff starts as 4 muscles attached to various parts of the shoulder blade.  Like all muscles they transition to tendons before they attach to the bone.  The 4 tendons of the rotator cuff cap the top of the humerus.  The job of the rotator cuff is to keep the ball of the humerus sitting on the very shallow joint it occupies.  

The shallowness of the joint allows it to have the remarkable range of motion it enjoys.  This joint moves our hands all over.  270 degree range of motion.  

So much of my time I spend talking to people about tears in their rotator cuff.  Not all tears require surgery. In fact, the vast majority of tears to not require surgery.  If you have a few nicks in the rotator cuff you can still rehab, strengthen and get rid of pain. Again the rotator cuff is still 4 muscles.  The other muscles can make up a bit for damage to one.  Additionally, just because there is a partial tear does not mean the muscle is shot.  Have you ever had a tear in your hamstring.  It still worked and you were able to get it back to a high level of functioning.  Remember 60% of 60 year olds have a tear in the rotator cuff.  They do not need surgery and maybe you do not either.  

February 17, 2012

Changing the way the world thinks about shoulder pain

I have been on an 8 year journey.  It started at 2AM in March of 2004.  I had my euraka moment as my shoulder was screaming in pain as it had done for many of the previous nights.  I was sitting in bed and pulled my wrist down towards the end of the bed.  Ahhhh that felt better.  I jumped up and went into my closet and got an ace bandage and tied one end to my wrist and the other end to some weights I had.  I had the weights hanging off the end of the bed and it was the best night sleep I had in several weeks.  

I awoke the next morning intrigued that this could help the masses I was seeing in my family practice with shoulder pain.  I tweeked the system and made it go from wrist to the leg with an elastic band and dropped the weights.  I will forever be indebted to some of my first patients that were guinea pigs for my contraption.  They told me what worked and what didn't. I tweeked some more. 

I wanted to be legitimate.  I wanted to do research.  I confessed to my wife that I had this dream and cobbled together $12,000 and commissioned a professional company to do the research.  The results were dramatic.  Everyone who used the brace got better.  I presented the research at the American College of Sports Medicine national meeting.  I was cheered.  

I thought my message would get out.  I thought the brilliant captains of health industry would embrace me. That did not quite happen.  All the companies told me they just could not charge enough for it.  Additionally it just cost too much money to teach doctors something new.  I was shocked.  I mean 40 million Americans have shoulder pain and I had the answer and they could not figure out how to get it to market.  

I licked my wounds.  I pondered.  I learned about internet marketing.  

OK we will go directly to consumers.  This time was a blessing because we were able to develop the best possible shoulder exercise regimen and add it to the product.

We became the Rotatoreliever.  

We started selling in August of 2010.  We have sold 2500 units (as of today).  The feedback has been remarkable.  We are so confident that it works that we have a money back guarantee (rare in a health related product).  The feedback has been unreal and humbling.  We have gotten 93 year old grandmothers and 22 year old MMA fighters better.  

This has been the most exciting project of my life.  Challenging for sure, but rewarding beyone belief.  

Thanks for reading and help me get the word out about the Rotatoreliever.

Dr. C

February 16, 2012

MRI and the shoulder

Boy, I really loved a recent article in the NYT that discussed.  It quoted our country's foremost orthopedic surgeon who spoke to the overuse of a test that just does not help that much.  

Check it out at http://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html?pagewanted=all

I loved his quote about if you want an excuse to do surgery just order an MRI.