Deep persistant pain in the shoulder can affect young and old alike. The causes, however, can be very different and require a thorough diagnostic process to understand the underlying problem and lead to a solution. Young, active patients often feel that there is an overuse syndrome. This may be the case, but it is important to understand why. Current exercise regimens usually emphasize strengthening the deltoid muscles, but the rotator cuff is largely ignored. This leads to an instability syndrome that can cause pain and even worse, a mechanical deficiency of the shoulder joint. If this is a chronic problem, with no history of a single traumatic event, the patient will usually respond to a strengthening therapy protocol that requires diligence on the part of the patient and therapist.
The most common cause of shoulder pain in older people is known as impingement syndrome. Bursitis is often an element of this syndrome and this frequently used term is much more accurate in depicting the problem than the term “arthritis”. Impingement refers to the mechanical process where the overlying bony arch of the shoulder (acromion of scapula and clavicle) is pressing on or rubbing on the underlying rotator cuff tendons and bursa. With age, the blood supply to the rotator cuff is diminished, and small microtears in the tendon leads to tendonitis and bursitis and even larger tears. This situation may respond to conservative treatment including a cortisone injection to reduce the bursitis, and shoulder therapy to improve the strength of the intact rotator cuff.
What does it imply to have a complete rotator cuff tear?
A complete rotator cuff tear implies that the torn tendon has pulled away from the bone and hence, cannot stabilize the head of the humerus against its cup joint (glenoid). The patient will either be unable to physically raise the arm or they can do this only with severe pain. This whole range of impingement problems is characterized by pain with elevation of the arm, pain worse at night, and inability to lie on the side of the affected shoulder. Once the pain is severe enough and does not respond to therapy and other conservative means, then surgery is indicated. Some smaller tears can be repaired through arthroscopic means, but larger tears are usually repaired through a traditional incision. Most repairs require a one month period of immobilization in a sling and several months of post-operative therapy closely directed by the surgeon. Local Barbadian, Karen Meakins, managed to win her 12th straight squash national singles title barely 6 months after similar arthroscopic rotator cuff repair, and then went on to take 4th in the world masters championship !! Many other citizens of Barbados also had arthroscopic rotator cuff repairs by Dr. Badia including local prominent physicians and community leaders. Shoulder pain should not be ignored and requires appropriate diagnostic studies and examination by a shoulder specialist. Dr. Alejandro Badia, Hand & Wrist Surgeon Miami, FL
Diagnosis and assessment of wrist pain in golfers and Tennis players can be particularly disabling to this group of sportsman. Bahamians have a long tradition in enjoying these sports, including the many expats that live in these very sporting islands.. In general, upper limb Injuries in golfers and tennis players are of two major types: The less common acute injury from a poor swing, or the much more common overuse injury or exacerbation of an underlying degenerative condition. The latter frequently occurs since golf and tennis is predominantly a game with older participants and players often demonstrate the common pathologies seen in the mature population. Ironically, many of these problems are seen much earlier due to the unnatural mechanism required in the upper limb during a golf swing or tennis stroke. ECU tendonitis is generally the most common cause of ulnar sided wrist pain, or the small finger side of the wrist.
The Extensor carpi ulnaris is a big tendon on the top of the wrist which gives the athlete follow through power on a stroke. Overuse can cause tendonitis and we often see small tears, as occurred to Juan Martin Del Potro, Olympic bronze medalist, who recovered in Miami after surgical repair. This was prior to the Olympics indicating that we can all recover from injuries if seen by the right specialist. The Triangular fibrocartilage complex (TFCC) is a cartilage structure deep in the wrist, similar to the meniscus of the knee. Tears can lead to debilitating pain and the diagnosis is difficult , even by MRI. Arthroscopy , a minimally invasive surgery using a fiberoptic camera, can not only diagnose but also repair the structure in a brief, outpatient surgery under local anesthesia.
On occasion, we may find a ligament tear of the wrist, usually the scapholunate or lunotriquetral ligaments, that need repair and possibly a temporary pinning, also all by arthroscopic means. It is critical to find a hand/wrist specialist that has particular experience in wrist arthroscopy and you can be back on the golf course or tennis court soon after recovery !! Dr. Alejandro Badia Expert Hand & Wrist Surgeon Miami, Florida
Arthroscopy is a minimally invasive surgical technique developed over three decades ago in order to explore a joint from within. Tiny incisions are used to insert a fiberoptic instrument which serves as a camera to the inside of a joint and allows a surgeon to not only diagnose a problem but often times allows definitive treatment. This is opposed to the more standard technique of open joint surgery, which can result in increased scarring and prolonged recovery time.
More recently, general and gynecologic surgery have also benefited from these endoscopic techniques and joint arthroscopy has enjoyed great success in both the knee and shoulder. Smaller joints now have also benefited from this technique. A smaller arthroscope has been devised in order to diagnose and even treat wrist pathology, which up until now has been a problem area. We have even used arthroscopic techniques to treat pathology in the basal joint of the thumb and knuckle joint of the hand.
The wrist is widely regarded as the most complex joint in the human body. There are eight carpal bones, which articulate with the two forearm bones creating a joint that moves in multiple planes. Wrist pain until recently has often eluded doctors due to the complexity and small size of this joint. Even MRI technology still cannot elucidate subtle problems with this articulation. The carpal bones are held together by small ligaments, which are often the subject of trauma and can lead to instability of these bones, leading to posttraumatic arthritis in the future.
The triangular fibrocartilage is a small cartilage disc, similar to the meniscus in the knee, which often leads to wrist pain along the ulnar or pinky side of the wrist. Tears in these ligaments can now be diagnosed and either debrided or repaired using arthoscopic means. The artroscope can also be used to resect inflamed joint tissue (synovium), remove bony, loose bodies, or treat articular fractures. The tiny holes made by the arthroscope also provide a more cosmetic means to treat wrist ganglions or cysts that are not only a source of pain but are quite disfiguring in a thin person’s wrist. The traditional open excision of this cyst leads to an ugly scar in a very visible place. The arthroscopic technique avoids this. As in other joints arthroscopy has broadened the horizons in hand and wrist surgery leading to improved diagnosis and treatment of complex problems that were previously untreatable and difficult to diagnose.
Dr. Alejandro Badia performed his undergraduate studies at Cornell University in Physiology. He obtained his medical degree at New York University where he subsequently completed his Internship in General Surgery and Residency in Orthopedic Surgery. He went on to a Hand and Upper Extremity Fellowship at Allegheny General Hospital in Pittsburgh Pennsylvania. This was followed by a traveling Hand Fellowship in Europe through the AO Trauma Association. He is a partner with Dr. Jorge L. Orbay, founder of the Miami Hand Center as well as Dr. Roger L. Khouri, formerly Director of the Microsurgery Fellowship at Washington University, St. Louis Missouri, and Dr. Eduardo Gonzalez, recently coming from Cleveland and training in Taiwan.