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Why Do I Have Pain Under My Knee Cap?

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Why Do I Have Pain Under My Knee Cap?
Pain under the knee cap, or patellofemoral pain, is a common issue I see. Learn more about this condition, the issues involved, and treatment options in this video.


 

What does it mean if you have pain underneath your kneecap, and what can you do about it?

Pain underneath the kneecap, also known as patellofemoral joint pain, is frequently described as pain underneath the kneecap, in front of the knee, around the knee as well. It’s typically pain that’s worse with prolonged standing, as well as if you’re going up and down stairs.

The patellofemoral joint is the articulation between the patella, also known as the kneecap, and the femur, the thigh bone. The structures that are involved there include the cartilage in between those two structures. Generally, there’s not very much fluid within that knee joint. There’s a normal alignment where the kneecap fits in the middle of the femur, along the trochlear groove. There are a number of soft tissue structures that are very key as well, including the ligaments, such as the medial patellofemoral ligament, lateral patellofemoral ligament, as well as the plica, that help to stabilize the lateral, or right and left motion of the kneecap. There’s also the quadriceps tendon and the patellar tendon above and below the knee that help to stabilize the kneecap as well. It’s also important to remember that the structures above and below the knee make a big difference in terms of what happens in the knee as well. So that would include at the ankle, the hip, and the lower back as well.

When there’s pathology or dysfunction in the patellofemoral joint, people are frequently complaining of pain in front of the knee, behind the knee, and around the knee. They frequently also describe swelling. Those symptoms, as well as classic examination findings, help to make a diagnosis of patellofemoral pain. Classic examination findings include the patellar compression test, where you compress the patella and have an individual contract their quadricep, and if they have significant pain, that can indicate that they have patellofemoral-related pain.

Imaging can make a big difference as well. X-rays can show whether the kneecap is properly aligned within the knee groove. In addition, it can also show if there is significant narrowing within the patellofemoral joint. Diagnostic musculoskeletal ultrasound is also helpful for looking for alignment. It’s also very helpful for telling if there’s any significant instability within the joint. You can also detect very small amounts of fluid that people may not actually be complaining of. MRIs are generally not to make this diagnosis. However, you can find swelling in the bone, also known as a bone marrow lesion, that can be seen if there’s significant stress within the patellofemoral joint.

Treatment for patellofemoral-related pain includes a number of different things. First and foremost, weight loss and ideal body weight can make a big difference. As much as possible as you can reduce excess body weight will help to reduce stress on the knee as well. Alignment is a big part of helping with knee pain as well, in particular, patellofemoral pain. Bracing, knee bracing can be helpful in that regard. Also in that regard, instability and alignment can also be improved with physical therapy. Strengthening the appropriate muscles of not only the thigh but also of the hip, can make a big difference as well in terms of patellofemoral-related pain. I frequently recommend over-the-counter supplements such as glucosamine, omega-3, and curcumin for knee related pain in general. That can certainly be helpful in patellofemoral-related pain also.

There are a number of different types of injections that can be helpful for patellofemoral-related knee pain. Steroid injections are most commonly given. It can give pain relief. Typically does not give longer term pain relief. It’s also not also very helpful and healthy for the joint long-term, so I generally try to get people to avoid that if possible. Hyaluronic acid injections can be useful for pain relief, in particular, if somebody has mild to moderate osteoarthritis. Dextrose prolotherapy is the first-line regenerative medicine treatment that’s helpful for mild to moderate patellofemoral osteoarthritis. It can help with not only pain but also instability due to hypermobility and chronic instability in the knee cap and the knee joint. Platelet-rich plasma is also helpful for moderate level osteoarthritis in the knee. Bone marrow derived stem cells are also helpful for more moderate to advanced level knee osteoarthritis and patellofemoral osteoarthritis. And also consider radiofrequency ablation, where you’re basically treating the nerves that cause pain around the knee as well.

The results to expect from these sorts of injection treatments generally include pain relief and functional improvement and getting back to a high quality of life. It’s not necessarily going to significantly improve what your imaging looks like on x-ray, ultrasound, or MRI. But if your goals are to feel better and to live a better lifestyle, then these kind of treatments can certainly make a big difference.

Surgery is generally not recommended for patellofemoral knee pain. Certainly arthroscopy does not make sense if you have knee pain from patellofemoral osteoarthritis in large part because there’s no evidence that it will actually help in terms of longer lasting pain relief in comparison to just physical therapy. Knee replacement, however, may be needed if you’re failing the above treatments that I’ve already mentioned.

I hope that gives some explanation and understanding of what’s going on if you have pain underneath the kneecap. If you found this content interesting and helpful, consider subscribing, giving us a like, and until we connect in the future, have a good day and live well. Bye bye.


 

What’s Causing Your Hand Pain?

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What’s Causing Your Hand Pain?
Pain in the hand, in particular the thumb, is fairly common. Texting, mobile phones, and work make thumb and hand pains more common. In this video I discuss how I approach diagnosing what is causing your hand pain. Topics discussed:
-Instability
-Inflammation
-Diagnostic musculoskeletal ultrasound


Hello everyone. This is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. Welcome to our Wednesday live stream. It’s October 21st, 2020, and excited to be here. Today we’re actually live streaming on Facebook, YouTube, Twitter, and IG. This is a technical marvel that I’ve been able to work this.

Today I am talking about something that I see really frequently which is hand pain. As a clinical rheumatologist, I get referred a lot of patients for hand pains in large part because inflammatory arthritis conditions including rheumatoid arthritis, psoriatic arthritis can frequently drive pain and swelling in the hands. So hand pains are a really common issue that I see. I had a patient earlier this week where I think understanding how to evaluate hand pains can clarify some things.

The interesting thing is that I think hand pains are becoming more common or more readily recognized for a few different reasons. Number one is because of the way that we all live, in the sense that we’re all constantly using our hands either on the computer, a laptop our mobile devices to constantly be texting emailing, and just doing kind of all of our work on the phones nowadays. It stresses our hands in different ways than what we’re used to traditionally. certainly I think texting thumb is starting to become a really common issue. so it’s something that I see a lot. I think on top of that is frankly, I’m more aware of hand issues, not only from a professional standpoint, but even personally since I do a lot of regenerative medicine injections you start to develop more discomfort over the thumb as well as you’re putting stress on that joint also. So hand pain is a very common issue and one that I think is interesting to talk about.

In the recent case of the patient that came to me, he was coming in with basically a history of progressive pains in both of his hands but really worse in both of his thumbs. He had had some x-rays done. He had also had some labs done and they were both benign. So the question was, what’s going on with his hands? So I always think of joint issues first and foremost, as what’s going on from an inflammation and instability standpoint. The reason why is because, that sort of sets me on a path of evaluation about how I want to look at that. There’s other issues that you have to look at as well, which I’ll mention but inflammation, instability are always key.

Instability is key because that is what really drives the overall degenerative process that you see in a lot of musculoskeletal conditions, including wear and tear arthritis, tendonitis, trigger finger, things like that. So instability, you make that evaluation and call based on what are you’re seeing in terms of examination findings, and what you’re seeing on ultrasound. So on examination findings, if there’s any evidence of increased mobility, laxity on exam, that can be a clue that maybe there’s some instability here. If someone comes in with a history of listen, I feel fine first thing in the morning, but as the day goes on, then as I’m using my hands more, it starts to hurt more, it’s a sign of instability in that joint likely. So that should clue you in that there may be a progressive stress issue, instability issue here. Then the last one is ultrasound. You need to be doing ultrasound and ultrasound to look for instability is fantastic.

In the case of this patient that I saw, he had x-rays that were normal and his examination was relatively normal, but on ultrasound, he had a little bit of instability, a little bit of laxity in one of his thumb joints. To me that is essentially diagnostic along with the other negative testing in terms of labs and all that, that here’s someone that has some early instability and degenerative process and stress developing in that joint. When you can make that kind of call, you can then start to guide somebody in terms of how to get them on the path to getting pain, relief, functional improvement and then hopefully also preventing this from progressing.

The other component is inflammation. So is there anything on exam, labs or ultrasound that would indicate inflammation. So classic history symptoms or history description of inflammation in the hands would be they wake up first thing in the morning. They haven’t used their hands but the hands are more painful and swollen at that time. Classic for inflammatory findings from inflammation. If you have inflammation throughout the body, that’s how that presents. It presents as inflammation, first thing in the morning, most prominently. Now you can get inflammation from instability as well. Meaning if there’s chronic instability it starts to irritate the joint, the tendons, the ligaments and then creates a sort of mild inflammation issue there. But that happens with stress on the joint and as you’re using it, not first thing in the morning. The other things to look for are, are there any labs that indicate inflammation? In this patient’s case there wasn’t and again, ultrasound, are there any findings on ultrasound that show that there’s fluid in joint, inflammation in the joint, anything else have a clue you’re into inflammation. In his case, there was not.

Ultrasound to me is key because it lets me go from a good physical exam. That’s very helpful and gives me some clues to then looking layers and layers deeper inside the body at the tendon, at the joint, at the ligaments, and give you a more accurate sense for is there any more definitive evidence of inflammation, soft tissue injuries, instability issues. X-rays, can’t give you that. It’s the reason why x-rays did not show his issue in my patient’s case, because x-rays don’t look at inflammation. X-rays are generally not so great at looking for instability because of how they take the x-rays. If you only take a static x-ray and that means you just, you take your hand and you just take a shot of that, then that’s a static image. It doesn’t show instability. On the other end, if you took a shot of your thumb moving, you might be able to find instability and they don’t routinely do that when it comes to x-ray imaging. Ultrasound imaging on the other hand, you can routinely do that because it’s right at the bedside, it’s easy to do. You tell the patient, either lay still and you move the joint or you tell them to move the joint and you can find the instability. So to me, ultrasound is key because the example would be if you came into a doctor saying you were short of breath and the doctor said, you look like you’re breathing ok. And he or she didn’t even listen to your chest for your lungs or your heart. Like that would be crazy. And for musculoskeletal medicine, you need to use ultrasound in order to really properly look at what’s going on underneath the skin. So to me, that’s how you look at inflammation, instability, where’s the evidence of one or the other, that guides me on the path for what’s the next step.

Now, there are definitely other things that can cause issues. Let’s say if you have a pinched nerve so you need to make sure you’re looking at the wrist, the elbow, the neck, is there any other evidence of where someone could be having pain from another source? Absolutely. But from initial evaluation, inflammation, instability, really, the first way to evaluate someone who’s got hand pains. In this patient’s case, that I’m describing, he has instability of his thumb joints on both sides, likely due to his job as a software engineer that’s causing stress and pain in both of his thumbs. We talked about a strategy for him involving initially some very basic things, working with a hand therapist and over the counter supplements. If that is not enough than likely escalating to platelet rich plasma where we can then treat not only the joint that’s unstable but also the ligaments to improve stability there as well.

So hand pains, really common thing that I see. I think something that we’re going to see a lot more of based on how we’re actually living as humans nowadays on our mobile devices. If you have a hand issue, that’s the right way to pursue it. Make sure you’re getting evaluated for both inflammation and instability, as well as figuring out if you may have a nerve related issue that could be causing hand pains as well. Make sure you’re getting a diagnostic musculoskeletal ultrasound as well. That will get you on the right path to a diagnosis and then eventually treatment.

Wonderful. So as a reminder, we do this live stream twice per week, Mondays and Wednesdays around 12 12:30 Central Standard Time. In addition, I’m doing a webinar today, 4 p.m Central Standard Time, on regenerative medicine treatments for shoulder pain. If you have a rotator cuff issue, shoulder arthritis, or just a shoulder strain, I think this webinar would be very helpful to listen to. I’ll actually be live streaming that on Facebook, Twitter, and YouTube as well. Until we talk again, have a good day and live well, goodbye.


***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
https://chicagoarthritis.com/schedule-a-telemedicine-appointment/

MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

How to treat Chronic Injuries- Regenerative Medicine approach

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How to treat Chronic Injuries- Regenerative Medicine approach
We all have chronic injuries. Even after recovering from an acute injury the involved area is more prone to long term degeneration, instability, and pain. In this video I discuss a healthier approach to managing chronic injuries that includes a regenerative medicine perspective. Key concepts include treating stability and inflammation. I also discuss a patient with chronic knee issues who with regenerative medicine has been able to continue his career as a active duty military professional.


***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
https://chicagoarthritis.com/schedule-a-telemedicine-appointment/


Hello this is Siddharth Tambar, from Chicago Arthritis and Regenerative Medicine. It’s October 14th, 2020. Welcome to our weekly live broadcast. So today I want to talk about how to address chronic injuries in a regenerative medicine style. So I’m a big football fan and it’s football season right now and there’s injuries happening left and right as the sport is expected to do. And when you see injuries you start to realize that there’s the acute nature of injuries in terms of what needs to be handled at that moment. But then, these people have chronic issues as well. And how should they be thinking about their issues and how can we better actually treat them. And reality is that for most of us, a lot of our musculoskeletal issues chronically will be from some mild chronic soft tissue injuries when we were younger at some stage of life. And so having an understanding of how to think about chronic injuries and chronic issues is key because it’ll make a big difference in terms of how you actually get a better outcome longterm. So number one, goals from treatment have to be pain relief, functional improvement, and keeping you active and exercising. And I think that’s across the board what goals should be for musculoskeletal issues but definitely for chronic injuries. And it’s important to understand that address this earlier rather than later, if you have chronic instability in an area that’s been previously injured, it’s going to make you more prone to osteoarthritis, tendonitis, longterm as well. And so you’re better off trying to address that at an earlier stage before it gets more advanced. You can still treat something when it’s become more chronic or more advanced but understand that it’s always better to treat it earlier. So if you, there’s a couple of key things that I would recommend. Number one, is stabilizing an area. So if you have an injury that is still relatively early acute or subacute, obviously the ways that you’re going to treat that are going to begin with bracing, physical therapy, if it’s severely traumatic or severely problematic or unstable then even surgery at that time. Obviously the classic example right now is Dak Prescott of the Dallas Cowboys who had a really severe ankle fracture injury or dislocation and obviously they’re going to treat that acutely in the proper way, surgically and bracing and resting and all that, longterm though because he’s got now chronic instability that will develop in that area because of injury to the soft tissue ligaments and all that, that he should be thinking about longterm, meaning five, 10 years down the line how does he prevent that from getting worse. That may not be on his mind right now, but it should be some point. I recommend that people should be thinking about regenerative medicine at an earlier stage of their recovery from a early injury, because there’s a lot of benefit to that. Whether that is taking injury that is not a surgical case and treating it at that stage or taking an injury that is actually a surgical case and when it’s actually been settled down to then actually apply either your own platelets or bone marrow drive stem cells makes a lot of sense at that stage as well. Chronically stability is really important because that what’s driving that chronic arthritic or chronic tendinopathy. And again, maybe some kind of bracing intermittently while you’re physically active can be helpful. I think it’s super important to do the corrective exercises either physical therapy or on your own longterm as well, because you need that kind of stability and strength around that area that’s been injured. In addition I think regenerative medicine utilizing your own platelets or bone marrow stem cells makes so much sense in a chronic injury because that’s what going to actually prevent that from getting worse. I think as much as possible if you have a chronic injury and instability, you want to try to avoid surgery. The issues with surgery are that most of the typical minimally invasive surgeries are about cutting out tissue that’ll actually leave that area more unstable longterm and actually potentially accelerate that degenerative process. And then the other component to that is, regenerative medicine is really made for those kind of cases in terms of helping to improve stability, helping to improve inflammation that’s where it really shines. So number two, kind of key concept is inflammation. So certainly if an area is inflamed, either acutely or chronically, rest, activity modification makes a lot of sense temporarily. I would strongly recommend avoiding using anti-inflammatory medications in large part because while they may be helpful short term, they just have too many side effects longterm. In addition, when you look at some of the supplements like curcumin, turmeric as well omega-3 we know that those kinds of issues can actually help in terms of inflammation and can actually help with wear and tear arthritis as well. And so strongly recommend that as well. You can use ice in a limited fashion. If you’re relying on it too often, I think you really need to make sure you’re seeing a physician expert in musculoskeletal medicine to make sure that you’re actually making that, you’re actually addressing the issue properly and that you’re not just masking the pain. A great example of this, is actually a patient of mine who had a PCL, posterior cruciate ligament injury in his knee several years ago. He’s active military still. He’s more on the training side now. But I essentially see him roughly every six months or so for PRP treatment. At which time we’re treating a number of different ligaments in the knee his PCL, his ACL as well as his medial collateral ligament and some of his patellofemoral ligaments and also treating the patellofemoral joint. What’s helpful in that case is we’ve been able to give him better stability, which has enabled him to continue to function and train at a very high level that he’s required to do as part of his work and in the military. In addition, it’s also helped in terms of just a day to day activities and pain relief as well. Taking a treatment that is relatively very limited in risk and invasiveness, right. And just injecting his own platelets to help keep him going at that kind of level, taking a chronic injury and helping him to stay that physically active is incredibly key. And again, it’s important to understand that most chronic degenerative issues, chronic arthritis or chronic tendinopathy patients are typically they’ve had a milder injury at some point and if you can treat some of those milder injuries at an earlier stage, you give yourself a better chance of preventing this from progressing. Wonderful, so that’s what I want to talk about with chronic injuries today. I see there’s a question that I have regarding chronic pain and also having MS. Is regenerative medicine a treatment option. Yeah, so from a chronic pain standpoint it depends on why you have it right. Is it chronic pain because, let’s say an area has been chronically weakened or unstable and has progressively become degenerative. If it’s at the level of the joint or tendon or ligaments, then that can be treated. If it’s higher up, let’s say at the level of spinal cord, I don’t think there’s enough evidence that’s really a proper treatment for multiple sclerosis at this time. There may be experts in neurology or neurosurgery that have a different opinion but at least from my perspective, I’m still possibly a candidate if the issue is at the level of the joint or the tendon, but probably not a candidate if it’s at the level of the spine. Great. Well, thank you very much for everyone’s time. As a reminder, we do this on Mondays and Wednesdays answering your questions, discussing concepts that are relevant to what we do here at Chicago Arthritis and Regenerative Medicine, focusing on nonsurgical, management and treatment of arthritis, tendonitis, injuries and back pain. In addition, I’m also doing a webinar today four o’clock central standard time. You’ll see a link for that below on whichever platform you’re watching where I’m discussing regenerative medicine treatments for lower back pain. Until next time, until we talk again, have a good day and live well. Bye bye


MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

Bone on Bone Knee Arthritis on Xray- What does that mean?

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Bone on Bone Knee Arthritis on Xray- What does that mean?

Bone on bone knee arthritis on xray does not necessarily mean knee pain.
In this video I discuss a study from Korea looking at advanced knee arthritis on xray vs pain.
-Treat the patient, not the image.
-Demystifying “Bone on bone” arthritis.
-Understanding the Regenerative medicine approach to treating the knee.
Treat all pain generators.
There are layers of pathology, treat all layers.
BMC Musculoskelet Disord. 2020 Sep 29;21(1):640.


***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
https://chicagoarthritis.com/schedule-a-telemedicine-appointment/
 

– Hello, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. Welcome to our weekly live broadcast is October 7th, 2020. Thank you for everyone’s time and I hope everyone’s doing well. So on this broadcast, I discuss concepts that are important with what we do here at Chicago Arthritis and Regenerative Medicine where we specialize in evaluation and management with nonsurgical options for arthritis, tendonitis injuries and back pain. So interesting study that came out recently that I think really exemplifies a lot of what Regenerative Medicine is about is an article that came out from Korea in the BMC Musculoskeletal Disorders Journal where they essentially looked at what does it mean to really have advanced osteoarthritis of the knee? So they looked at three large national databases in South Korea. They had a total of 20,000 people and roughly 10% of them had advanced knee osteoarthritis on x-ray. That’s probably to be expected in a large enough cohort of people that 10% of them would have KL4 degree osteoarthritis. And what they found that was that up to 30% of them were asymptomatic without any symptoms of pain or loss of function that they were describing due to their knee arthritis. That’s interesting because for physicians we frequently talk about how you should treat the patient and not treat the image. And yet it’s very frequent when it comes to musculoskeletal medicine that people will look at someone’s knee x-ray and will tell them “Well, you actually have bone on bone, knee arthritis, and you should consider knee replacement surgery.” And that’s regardless of how significant our pain is or dysfunction is or if they’ve even failed other treatment options. And so that concept of treat the patient not the image is really exemplified here because just having severe osteoarthritis on the X-Ray did not necessarily mean that you’re going to have really significant pain. And in this article, they have this last line where they say, “Treatment options focusing solely on cartilage engineering should be viewed with caution.” It’s a really great line because there is a developing industry in orthopedics that’s based on actually trying to repair small cartilage lesions. The idea being that a person’s pain is coming from the amount of cartilage damage, as opposed to the stress on the bone or the other soft tissue structures. And this is a great study because you know that even when you have someone that has advanced arthritis of the knee that that’s someone who can still respond very well with regenerative medicine approach to treatment. In fact, the evidence out there shows that the degree of arthritis in the knee does not make a difference when it comes to utilizing your own bone marrow derived STEM cells when it comes to treating that knee arthritis. On the other hand platelet rich plasma sometimes can be worse and not as effective in some of those more advanced arthritis, but your own bone marrow cells definitely can still be helpful. So, and part of that comes from an understanding of how regenerative medicine works. Meaning number one, you want to treat all the pain generators. It’s not just looking at how much cartilage wear there is but it’s also what else is going on in that joint. Is there any degree of chronic inflammation? Is there any sort of chronic stress on soft tissue structures, meniscus, ligaments, tendons? Is there any sort of nerve or muscle related issues? How can you maximize? Not only the cellular health within the joint. How can you produce chronic inflammation. How can you improve stability of the joint by improving the soft tissue structures as well. And really improving the overall joint and what’s driving pain. Understanding that degenerative process in a knee is not just how much wear there is on the cartilage that you see on an X-Ray or an MRI but really it’s the entire structure that’s pathologic. And how do you actually make that whole structure better. And the last part of that is understanding that there’s layers of pathology in someone that’s got degenerative arthritis of the knee, and you need to address all those layers. And so a classic mistake that I see from physicians who dabble in regenerative medicine, is that when it comes to treating an arthritic joint they’ll only inject cells into the joint. They don’t actually treat the whole structure meaning all those other soft tissue structures and those layers and layers of pathology. It can make a big difference from someone who has a average or even mediocre result from treatment to somebody who has a really great result to treatment. That understanding that it’s not just what is an X-Ray look like on a knee, but treating that whole structure and the whole patient as well. And so understanding that you treat the patient and not the image is something that I think for everyone out there it’s important to understand that because even if your physician says that and believes that a lot of times your actions don’t necessarily showcase that. And a proper regenerative medicine expert really understands that and will do a better job of treating the whole structure, the whole joint to give you pain relief and functional improvement. Great, well, I hope that clarifies some understanding of bone on bone arthritis that’s described on x-rays frequently. As a reminder, we do this on Mondays and Wednesdays. In addition, I’m doing a webinar today 5:00 PM central standard time on regenerative medicine treatments for the knee. If you’re interested, just see our link attached to this video. And until next time have a good day and live well, bye bye.

MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

Issues with Shoulder Impingement Surgery

shoulder impingement surgery

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Issues with Shoulder Impingement surgery

Shoulder impingement results in pain with lifting your arm above your head. The typical surgery for this involves shaving the acromion bone to make more room for the rotator cuff to more freely move. But does this surgery work?

A recent article from the British Journal of Sports Medicine shows that shoulder impingement surgery is no better than physical therapy alone or a diagnostic procedure where no intervention is done.

What does this mean to you if you have shoulder impingement?
-You can likely skip surgery and maximize the nonsurgical alternatives for your shoulder pain.
-Get a specific and accurate diagnosis from a physician who focuses on shoulder and musculoskeletal issues.
-Have a diagnostic musculoskeletal ultrasound of your shoulder to evaluate for rotator cuff tear and instability.
-Maximize exercise options including physical therapy.
-If inadequate, consider a regenerative medicine treatment to improve stability of the shoulder that is causing impingement. Also improve the shoulder by optimizing it’s biologic health, reduce inflammation, and improve the neuromuscular components.

Paavola M, Kanto K, Ranstam J, et al Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial British Journal of Sports Medicine  Published Online First: 05 October 2020.


***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
https://chicagoarthritis.com/schedule-a-telemedicine-appointment/

– Hello, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. It’s October 12th, 2020. Welcome to our weekly educational meeting. This is live streaming currently. And on this meeting, weekly, I’m discussing concepts related to what we do here at Chicago Arthritis and Regenerative Medicine, answering questions that I frequently get from staff and patients, and also discussing just general big picture musculoskeletal concepts in terms of how we’re trying to treat people and get people better here. As a reminder, we’re focused on nonsurgical management of arthritis, tendonitis injuries, and back pain. And so it’s an interesting time because there’s a ton of information that’s coming out progressively about comparative studies, what works, what doesn’t work. There’s an interesting article that came out in the British Journal of Sports Medicine recently about shoulder impingement surgery. So shoulder impingement essentially means that when you’re trying to lift your arm up, that it catches and causes pain and dysfunction. So the traditional surgical approach to that was to do what’s called subacromial decompression or acromioplasty, and what that means is going to the bone, the acomion that sits over the rotator cuff, shaving it down to, in theory, put a little bit of more space for the rotator cuff to flow a little bit easier. It’s an interesting idea. May make sense from a surgical and structural standpoint, but in the last few years, there’s been progressive evidence that that may not be better than physical therapy. So in the British Journal of Sports Medicine, an article recently published by a group of physicians from Finland basically compared the effectiveness of this surgery in a interesting and unique way. They essentially took 175 patients who had shoulder impingement, and that was defined by reduced range of motion with abduction, internal rotation, and that was diagnosed clinically. They made sure that they took out patients who already had a significant rotator cuff tear or a significant osteoarthritis. They gave them a diagnostic injection meaning injecting some local anesthetic into the shoulder bursa space. And if they had a significant improvement in pain indicated that they had shoulder impingement and then included them in this study. The idea being that they wanted to kind of exclude out people that may have neck issues or some other issues, and really focused in on this category of patients. They split them up into three different groups. The first one being patients who progressed with shoulder acromioplasty, the surgery. The second were patients that had a diagnostic arthroscopy. And that means that they had a surgical procedure, but it was strictly one that was looking at what’s actually going on in the shoulder, not one that was actually doing any additional intervention. And number three, they also looked at a group of patients that also had just physical therapy. So in all of these patients had already failed some kind of exercise therapy and they excluded out those other patients that I mentioned and they then compared the effectiveness of the interventions. And so the patients that had surgery, subacromial decompression, they found that there was no significant improvement compared to the patients who just had the diagnostic arthroscopy or the patients that had just physical therapy. And they followed them out over five years and found that there was no difference during that time. Really interesting. Why is this important? Number one, if you compare surgery to nonsurgical treatments, there’s higher risk associated with surgery, whether that’s due to anesthetic risk, conscious sedation risk, nerve block risk, bleeding, tissue damage, other kinds of issues like that. There’s just higher risk than anything that’s nonsurgical. So if surgery is not more useful, then why go that route, right? Always consider other options. The other interesting component here is that the structural model of musculoskeletal care, which says look at your x-ray, you may have a little bone spur. We need to shave that off, but that does not seem to play out as well as people think it does. It may make some intuitive sense but that’s not actually how the body works. Understand that arthritis, tendonitis, is more of a biologic functional issue, and not as much of a strictly structural model of care is important. And it’s likely the reason why in this study that even though they did an intervention, the subacromial acromioplasty, the surgery, there was no additional benefit compared to just a diagnostic procedure and compared to just physical therapy. So super, super important to understand that. And so then it comes down to, what are your nonsurgical options and alternatives for shoulder pain from impingement? So number one absolutely, you need to maximize physical therapy. Exercise therapy is humongous. Doing the right exercises is really important. If that fails, however, number two, you then need to determine, do you have some other cause for this kind of problem? Do you have a rotator cuff tear? Do you have any significant arthritis involved? I would recommend getting that evaluated with a diagnostic musculoskeletal ultrasound. Under a trained hand you can really find some very fine details in this regard. Number three, you want to then also determine is there any kind of neck issue going on? And the reason why is because if you have a neck issue, it can really look a lot like a shoulder issue as well. So you want to make sure you’re not possibly confusing these. And then number four is if there’s no other significant rotator cuff or osteoarthritic process that I would recommend a treatment like platelet rich plasma treatment if you’re still having pain. The key here to understand is that you don’t want to just inject that into the bursa around the rotator cuff. You want to do better than that. Number one, if there’s any even mild fraying of the rotator cuff, you want to make sure to treat that. Number two, if there’s any evidence of strain on the AC joint, essentially the joint where the rotator cuff runs underneath. If there’s any evidence of strain on that, either on examination where you’re having symptoms or an ultrasound, you would then want to inject into that joint as well, your own platelets. And then lastly and likely most importantly is that you also want to treat all the ligaments that are leading to that instability as well. Instability is really what this is about and that’s what’s causing the impingement. And so if you have that space where the rotator cuff is running is getting impinged and squeezed down upon, you want to make sure that you appropriately treat all the ligaments that are leading to that instability. And the reason why is because if you do, you’ll give your shoulder a better chance of recovering from that injury. You’ll give your shoulder and rotator cuff a better chance of not getting progressively damaged, and you’ll give your AC joint above your shoulder a better chance of not becoming arthritic as well. So shoulder impingement surgery- no better than just physical therapy or just a diagnostic evaluation. Maximize your nonsurgical alternative options. And if you’ve already done that, then instead of proceeding with a surgery that shaves off the bone, that is no better than just physical therapy, I would recommend proceeding with the regenerative medicine treatment in a proper manner where you’re treating the whole structure, the whole functional unit to get that better. Great. Thank you very much. As a reminder, I’m doing this twice per week, Mondays and Wednesdays. In addition, this Wednesday evening, I’m also doing a webinar on regenerative medicine treatments for lower back issues. And until we talk again, have a good day and live well. Bye bye.


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