OA Update: Injury Prevention, Athletic Performance and Orthopedic Procedures

Carpal Tunnel Syndrome - Symptoms and Treatment Options

By Sacha D. Matthews, MD

The carpal tunnel is a narrow, rigid passageway composed of the transverse carpal ligament and the carpal bones in the wrist through which nine flexor tendons and the median nerve pass. Carpal tunnel syndrome (CTS) develops when the median nerve is pinched within this tunnel. The median nerve provides sensation to the thumb, index, middle, and ring fingers and also supplies small muscles in the thumb that coordinate its movement.

Some of the most common symptoms of CTS include:

• Burning, tingling, or numbness in the palm or fingers

• Nighttime awakening due to numbness or pain

• Desire to “shake out” the hand or wrist

• Difficulty grasping small objects

It is not just repeated use that causes carpal tunnel syndrome. An injury to the wrist or mechanical problems can also be to blame. Even fluid retention from pregnancy or with certain medical conditions can cause CTS. Carpal tunnel syndrome is often the result of a combination of factors that increase the pressure in the carpal tunnel. Contributing factors may include: hypothyroidism, rheumatoid arthritis, work-related repetitive use, use of vibratory tools, or the development of a cyst or tumor in the carpal tunnel. In many cases, no specific cause can be identified.

 

Treatment of Carpal Tunnel Syndrome

The goal of treating carpal tunnel syndrome is to return to normal function and activities and to prevent ongoing nerve damage, which can result in a loss of sensation and muscle strength. Treatment is based on the severity of the condition, whether there is any nerve damage, and whether other treatments have helped. Treatment options include nonsurgical and surgical methods.

Hand surgeons agree that the earlier CTS is identified and treated, the better the results. Carpal tunnel syndrome is diagnosed by history and physical examination. An EMG (nerve test) is often ordered to confirm the diagnosis and evaluate its severity. In mild carpal tunnel syndrome, splinting to avoid bending the wrist in combination with anti-inflammatory medicines, occupational therapy, and corticosteroid injections can alleviate the pain and numbness from CTS and can even be curative. More advanced carpal tunnel syndrome may require a carpal tunnel release — a surgical procedure, during which more space is created for the median nerve by cutting the ligament covering the tunnel. A carpal tunnel release is typically done as an outpatient procedure by a qualified surgeon.

Sacha D. Matthews, MD, is an orthopedic hand specialist and hand surgeon at OA Centers for Orthopaedics Hand Center.  

Hip Replacement Options for Active Adults – The Birmingham Hip Resurfacing System

By Brian McGrory, MD

Fifty years ago the miracle of total hip replacement was that it allowed patients with severe arthritis to walk, sometimes for a decade or more before needing another surgery. Today, hip replacement surgery is one of the most successful operations performed, and most experts feel that 20 or more years is the lifespan of the artificial joint. Newer biomaterials (the substances that artificial joints are made from) have allowed surgeons to return to an older design of hip — the resurfacing hip replacement. This may have led to a breakthrough in what patients can expect after their total joint surgery.

“A week doesn’t go by that I have to tell a patient that he or she has to give up running because of hip arthritis,” says Dr. Brian McGrory, a hip replacement specialist at OA Centers for Orthopaedics. “When I found out that Dr. Derek McMinn, the developer of the Birmingham Resurfacing Hip, had patients that were not only running, but running competitively in long-distance events, I was very intrigued.”

Dr. McGrory visited Birmingham, England, and learned the resurfacing technique that Dr. McMinn had perfected. As one of the only surgeons trained to perform this procedure in Maine, Dr. McGrory sees many patients who have an interest in the Birmingham Resurfacing Hip.

“I’m very selective for whom I offer the hip resurfacing system because the outcome depends on picking the right patients for this surgery,” Dr. McGrory says. The patient’s degree of arthritis, age, sex, bone strength, and bone shape all must be right for the surgery to work. Even following these criteria, 1 to 2 percent of patients have early failure of the replacement. This compares to less than 1 percent of patients with a more traditional hip replacement. The fact that some surgeons allow patients to run after resurfacing hip replacement and that patients feel like they can run does not make it the right thing to do. Unlike a normal joint, the metal-on-metal implant does wear and can’t repair or regenerate itself. Whether the amount of wear is insignificant, and if the body can dispose of the metal breakdown products, remains to be seen.

“For my patients who believe that they must run, I’ll allow them to do so if everything looks good and a year has passed since their surgery (research has shown that the femur strength is increasing up to one year after surgery),” Dr. McGrory says. “Time will tell if their new hip can take it. Patients in this category are, in my view, taking a calculated risk.”

When failure occurs with resurfacing hip replacement, revision to a conventional replacement remains an option because more bone remains and may be better than a standard revision. A recent study showed that a revision of a resurfacing hip replacement is tolerated like a first-time hip replacement for most patients. Because the current style of resurfacing is a relatively new procedure, with a small number of patients being appropriate candidates, only the largest centers have had extensive reoperation experience for failed resurfacing hip replacements.

“Patients often ask what is the best hip,” Dr. McGrory says, “and are astounded that there is no straight-forward answer. The newest technologies and techniques do not have enough follow-ups to know which, if any, will be better than the current gold standard. At OA, we have an approach that is both conservative and cutting-edge.”

Clinical follow-up studies in ceramics, metals, and cross-linked polyethylene are ongoing, as are studies assessing newer approaches to surgery and speedy recovery. “OA surgeons strive to bring safe, proven techniques to Maine. At the same time, we want to take advantage of potentially better innovations for our patients. Our focus on subspecialty care and follow-up of our patients allows us to achieve these seemingly disparate objectives,” Dr. McGrory says. Not all patients are candidates for resurfacing hip replacement surgery, but all have common goals for having surgery: reduced discomfort and restored function. The physicians at OA’s Joint Replacement Center are committed to achieving those goals.

Brian McGrory, MD, is an orthopedic surgeon specializing in hip replacement surgery and hip resurfacing using the Birmingham Hip Resurfacing System. The Birmingham Hip Resurfacing System is the only FDA-approved hip resurfacing system available for use in the United States. Hip resurfacing is an alternative to traditional total hip replacement for some arthritis patients.

 

 

 

 

When Does Shoulder Pain Necessitate Shoulder Surgery?

by Thomas F. Murray, Jr., M.D.

Shoulder pain affects millions of people worldwide, and rotator cuff disease is one of the most common causes. The rotator cuff is a group of muscles and tendons that help stabilize the ball-and-socket joint of the shoulder. The rotator cuff acts to keep the head of the humerus (the bone that runs from the elbow to the shoulder) centered in the glenoid (shoulder socket) as the arm is raised from the side.

Rotator cuff disease is actually a spectrum of pathology ranging from tendonitis to actual tearing of the rotator cuff tendons. This problem can develop both from intrinsic causes — aging, circulatory compromise, and degenerative changes — and extrinsic causes — trauma or repetitive overuse. Repetitive heavy lifting and overhead work are also common causes and may lead to impingement syndrome or rubbing of the rotator cuff on the bone above it.

Symptoms of rotator cuff pathology typically include pain in the outer shoulder and upper arm, pain at night and with overhead activity, snapping or cracking in the shoulder, and weakness. Upon examination, the physician may note weakness as well as limited range of motion. Radiographs may provide clues to rotator cuff disorders, but magnetic resonance imaging (MRI) has become the diagnostic standard. Just as television picture quality varies greatly, so too do MRI images. Open and extremity MRI machines may sound like a more convenient and comfortable option, but they are typically plagued by poor image quality. Consumers should be sure that if they require an MRI, it is performed with a high quality magnet.

Treatment decisions for rotator cuff disease should be made based on the extent of damage to the tendons. Tendonitis and superficial partial tearing can usually be managed by conservative (nonsurgical) means. A stretching and strengthening program to improve rotator cuff function is the hallmark of conservative care. Physicians may choose to add nonsteroidal anti-inflammatory medications (NSAIDs) to reduce pain and discomfort, particularly during the early phase of rehabilitation. Corticosteroid injection may also help if NSAID therapy fails. Full thickness or high-grade partial thickness tears may be treated conservatively if medically indicated. While the tear will not truly heal, nonsurgical care can be effective in reducing symptoms and improving function and is most appropriate for sedentary patients who have a lower success rate with repair.

In active and healthy patients with rotator cuff tears, operative repair or shoulder surgery is the standard of care. Fortunately, arthroscopic (minimally invasive) techniques have provided significant improvements in patient outcomes requiring rotator cuff surgery. A number of studies have demonstrated less postoperative discomfort and improved long-term patient satisfaction with arthroscopic treatment. Arthroscopic (minimally invasive) surgical techniques typically reduce patient discomfort and recovery time.

Open repair remains appropriate for tears of the anterior (front) rotator cuff or in combination with other open procedures. Rotator cuff repair patients should anticipate a four-to-six month recovery period, including four to six weeks of sling use, two to three months of physical therapy visits, and a home exercise program as well.

Regardless of the type of repair utilized, a well-controlled rehabilitation program is critical to a satisfactory outcome. Since rotator cuff disease can be a progressive, degenerative problem, patients with persistent or worsening shoulder pain should contact their primary care physician or orthopaedic surgeon. Improved outcome and patient satisfaction are both tied to early identification and treatment of this problem.

 

What to Do When Should Pain Occurs

If you are unsure of the cause of your shoulder pain, or if you do not know the specific treatment recommendations for your condition, you should seek medical attention. Treatment of these conditions must be directed at the specific cause of your problem. Some signs that you should be seen by a doctor include:

• Inability to carry objects or use the arm

• Injury that causes deformity of the joint

• Shoulder pain that occurs at night or while resting

• Shoulder pain that persists beyond a few days

• Inability to raise the arm

• Swelling or significant bruising around the joint or arm

• Signs of an infection, including fever, redness, and warmth Reasons and remedies for rotator cuff disease

Dr. Thomas Murray, Jr., M.D. is a sports medicine specialist and orthopedic surgeon. Dr. Murray specializes in arthroscopic surgical repair of the shoulder and knee.

Dupuytren’s Disease: What is it? How is it treated?

by Sacha Matthews, MD, and Sarah C. Starbird, PA-C 

Dupuytren is a disease involving the palmar surfaces of the hand, and very seldom, the feet. The tissue just below the surface of the skin, called the fascia, thickens abnormally, causing firm lumps or cords that can extend from the palm out to one or more fingers in the affected hand. Over a period of time these thickened cords can shorten, pulling the finger(s) down into the palm and making it difficult to perform many functions such as shaking hands, wrapping the hand around a glass, wearing gloves, or putting the hand into a pants pocket. Fortunately, the deeper structures of the hand including arteries, veins and tendons are not directly involved. Nerves can be intertwined with the cord, making it a difficult dissection if surgical excision is elected.

The cause of dupuytren is not known but it does tend to run in families—particularly those of Northern European descent. It is also common in men over the age of 40. Many times the facial thickening starts and then remains a small, painless bump in the palm. If this is the case, then no intervention is necessary. However, if the nodule progresses into a cord that begins to pull the finger(s) down into the palm, resulting in a functional deficit, then referral to a hand specialist should be considered. This process of tethering and contracting usually takes months, if not years, to advance, thus leaving plenty of time to consider if and when anything needs to be done.

Treatment options depend on the severity of the disease. As mentioned above, an isolated painless nodule in the palm needs no more treatment than a watchful eye. Even a more advanced cord needs no treatment if it is not interfering with hand function. Concern for treatment arises when daily life activities are affected and improvement in finger extension is desired by the patient.

Surgery, along with the newly approved collagenase injections from the Federal Drug Administration (FDA), are two of the options available. Collagenase is injected by a hand specialist into the tissue. This dissolves the cord over a period of 24 hours, allowing it to be manipulated and straightened. Splinting and therapy follow. Unfortunately, this treatment is not covered by most insurance carriers and needs to be paid for out of pocket, which makes it too expensive for most patients.

Surgical excision of the cord(s) removes the diseased tissue and allows the finger(s) to straighten and function normally. This procedure can typically be completed as an outpatient surgery. It takes between one to two hours to perform the surgery, depending on the severity of the disease. A post-operative splint is worn for several weeks post-surgery, to keep the finger(s) in an extended position. Therapy is recommended to assure optimal post-operative success.

The disease can reoccur over time despite all attempts. Keeping this as well as the operative and injection risks in mind, overall goals and expectations should be discussed thoroughly with a hand surgeon prior to any invasive procedure.

Sacha Matthews, MD, is a hand surgeon in the OA Hand Center. Sarah C. Starbird, PA-C, is a physician assistant who works in the OA Hand Center with Dr. Matthews.

Sprained SC Joint Reported for Brett Favre

Brett Farve went down hard in Sunday’s game against the Buffalo Bills. Bill’s linebacker Arthur Moates tackled Favre from behind on the first play of the game, injuring Favre’s shoulder and ending his game. Subsequent reports from ESPN indicate that Favre sustained a “sprained AC joint” injury. An MRI today is expected to confirm reports.

According to sports medicine specialist, Dr. Tom Murray, the SC Joint, or sternoclavicular joint, is the connection of the sternum (breastbone) to the clavicle. An SC joint injury is not a common injury, and it can be problematic, particularly for an aging NFL quarterback. Dr. Murray notes that usually SC joint symptoms arise from arthritis, a possible consequence but not the cause of Favre’s Sunday injury. Treatment includes cortisone injections, and may be Favre’s only hope of recovering fro the SC joint injury prior to next Sunday’s game against the New York Giants.

 

 

 

 

 

Cycling Commentary Offers Insights on Cycling and Cycling Performance

We understand that Ted Darling is back and writing on his blog, Cycling Commentary. Aptly named, Cycling Commentary provides insights into the world of professional cyclcing as well as the author's own personal musings. But in a new twist, Cycling Commentary now provides insights into cycling performance based upon the blogger's experiences as an endurance athlete.