Rotator Cuff Tears

By Ron Romanelli, MD

The shoulder is a very interesting joint. It has the most motion than any other joint in your body. If you think about it we use our shoulder every day for almost any activity that we need to do. We really don’t even notice that we have a shoulder until it becomes hurtful.

The shoulder joint has a global motion, what I meant by that is it allows us several degrees of freedom of movement. Our shoulder girdle consists of the shoulder blade (socket), the upper humerus (ball) and the clavicle. The shoulder and arm is essentially suspended from our body. There are some large muscles around the shoulder and then there are the rotator cuff muscles which have to do with the rotation and elevation of a ball within our socket.

The four muscles that make up the rotator cull include the supraspinatus, infraspinatus subscapularis and Teres minor muscles. There is also ligaments and the glenoid labrum ring or O-ring in the joint that helps render stability to our shoulder.

During shoulder movement, typically a synchronous movement of the scapula along with the humerous allows the muscles to work together to move the arm in a nice smooth delicate motion. Overuse of the shoulder as well as imbalance of the muscles contribute to tendon tears and internal derangement of the shoulder.

Roator cuff tears can occur due to several factors. Mechanical impingement from bone spurs and overuse rotator cuff tendinitis can lead to tendon degenerative changes over time. Acute injury to the shoulder can lead to failure of the rotator cuff. Next we have to consider aging and genetics that also contribute to degenerative tears in the rotator cuff tendon. Next, if the combination of all these factors working together which can cause degenerative rotator cuff tears and pathology.

Rotator cuff tears can be partial or complete. The complete tears are classified as small, medium, large, and massive. The most common rotator cuff tear is the supraspinatus tear. This is the muscle that elevates the arm forward and upward.

Just like fractures every rotator cuff tear seems to have its own personality. Therefore we treat those injuries based on the personality of the tear and injury as well as the situation of the patient. What I mean by this is that not all rotator cuff tears are alike nor not all rotator cuff tears need to have surgery.

Surgery is reserved for people who have persistant pain and/or weakness of the shoulder that is not able to be treated with conservative measures. We typically start with the history of the injury and the evaluation of the patient. Initial treatment consists of medications and occasionally cortisone injections, and physical therapy. If our conservative treatment fails then surgical treatment will be needed. This again depends on the age of the patient as well as the type of tear that is present.

Most of the time when patients come in with shoulder pain we can diagnosis and treat them with conservative methods and approximately fifty to seventy-five percent of the time the patient will get better. If patients fail conservative treatment and are unable to perform the tasks they desire, then shoulder surgery is needed.

Historically, rotator cuff tears have been treated with open surgical techniques. Currently the majority of orthopedic surgeons utilize arthroscopic surgical techniques for rotator cuff pathology. These techniques are performed in an outpatient facility such as the Orthopedic Surgery Center of Illinois using a specialized team of nurses and nurse anesthetists and anesthesiologists. We utilize a very light minimal general anesthetic as well as a shoulder pain block and local anesthesia typically to perform these procedures. The shoulder blocks and local anesthesia typically will numb up the shoulder for approximately 24 hours after the procedure. This way patients can have this procedure performed as an outpatient and then utilize ice and take pain medications for just a few days after the procedure.

We typically utilize cutting-edge techniques for performing these procedures. The orthopedic surgeons at OCI have under taken specialized training to perform this procedure. Most of us utilize a double row rotator cuff tear technique which is able to repair the tendon to the bone more securely, which we feel is the best way possible for the best recovery and outcome.

When dealing with rotator cuff surgery the patient needs to understand that there is a physiological healing process that must occur before we load the tendon. It takes approximately six weeks time to have the bone and tendon bond together. Then the next six weeks we work on range of motion and strengthening progress to achieve success.

Patients need to understand though that getting an unhealthy rotator cuff tendon to heal back to the bone is somewhat of a lengthy process. Approximately three to six month after the injury we still recommend strengthening program to continue. Typically the maximum healing will occur six months to a year after the surgery. This is not to say that patients don’t feel better soon after the procedure. Patients usually can tell a difference within a week or so after surgery because they do not experience as much pain as they had preoperatively. What I’m trying to say is that we need to understand that rotator cuff tendon healing may take a little bit longer time to heal before we allow unlimited use. Certain people tend to heal faster than others and certain people can have some complications associated with the rotator cuff surgery. The typical problems that occur after a rotator cuff surgery would be stiffness and the need for more physical therapy than usual. Infection, bleeding, and nerve injury are all very rare.

The prognosis of rotator cuff surgery is sometimes dependent on the personality of the tear and the age of the patient. Remember there are small tears, medium tears, large tears, and massive tears. Of course the small and medium rotator cuff repairs usually have an excellent prognosis, especially when we perform this on younger individuals. Small and medium rotator cuff tears can still heal in older individuals, but this depends on how long the tear has been present as well as the physiological age of the patient. When we deal with a massive rotator cuff tear the prognosis is not always as good.

Please remember that there may be acute tears in a normal shoulder that usually will heal well. That is the type of injury that happens when you had no problem with your shoulder and all of a sudden injure your rotator cuff. The patients that are difficult to treat have been having some shoulder pain for awhile and may have had some rotator cuff damage already and then go on to tear the rotator cuff completely and are unable to lift their arm. These cases are very difficult to treat and occasionally need to be treated with a reverse total shoulder replacement. This is a total joint procedure that is performed for older people who have extremely poor rotator cuff tendon tissues. This is a decision we have to make after we evaluate the patient and perform a MRI scan so we can see what is actually going on with the rotator cuff. If the rotator cuff has fat atrophy that means it has not been working normally for a long time, therefore the surgical results will not be good. Also people have a bad prognosis if they are smokers, because this will inhibit the healing of the tendon back to the bone.

One of the extremely important ways for you to recover after your rotator cuff surgery is by going to physical therapy. We know that the role of the physical therapist valuable in teaching the patients the proper techniques and protocols for success after rotator cuff surgery. Therefore we rely on our PT specialist at Midwest Rehab to come up with a custom treatment plan for each particular problem based on the patient’s surgical findings and individual rotator cuff tear.

The best way to deal with your rotator cuff problem or shoulder pain is to be evaluated by your orthopedic surgeon. We will be able to perform a special physcial examination on your shoulder, take x-rays, and decide whether a MRI would be needed. Once we evaluate the problem we can decide what the best treatment plan would be for your particular issue. We always start with a history and physical evaluation, the possibly anti-inflammatory medications, cortisone injections, and physical therapy before resorting to surgery.

The physicians at the Orthopedic Center of Illinois are always striving to do our best to give you the proper medical care and service you deserve.

Community Education: “Fingertips to Forearms; An Overview of Ailments”

Join orthopedic surgeons Ashkon Razavi, MD and Chris Maender, MD, for a free seminar to discuss an introduction to hand and wrist surgeons and an overview of surgical MaenderRazavi Ashkon 2015 done moreand nonsurgical treatments for issues in the elbow to the finger.

Wednesday, October 14  6:00-7:00 p.m. Location: Orthopedic Center of Illinois 1301 S. Koke Mill Rd, Springfield

Light refreshments provided. Reserve your seat today! Call (217)547-9100

Community Education: “Stenosis & Sciatica: Nonoperative and Surgical Treatment”

Join orthopedic surgeon, Joseph Williams, MD, for a free seminar to discuss
both nonoperative and minimally invasive surgical options to treat nerve pain in both the neck and back.JosephWilliamsRD copy

Monday, August 10  6:00-7:00 p.m.
Location: Prairie Heart Institute at St. John’s Hospital
619 E. Mason, Springfield

Light refreshments provided. Reserve your seat today! Call (217)814-4308

OCI Named “Good As Gold”

TAV Good As Gold 1 wb

Dr. Tim VanFleet accepted the Good as Gold award on behalf of the OCI Board of Directors April 15.

For the second year in a row, OCI was named “Good as Gold” by the University of Illinois Springfield, the Junior League of Springfield and the United Way of Central Illinois! The Good as Gold ceremony, held on April 15, 2015, recognized community volunteers and organizations who improve Springfield through volunteering their time and financially supporting programs that make an Good AS Gold Cert 1 wbimpact in the community. Thank you to the presenters and the hard work of the Good as Gold committee for a lovely event!



Minimally Invasive Treatment of Sciatica

By Joseph Williams, M.D.
Board Certified Orthopedic Surgeon
Orthopedic Center of Illinois

Sciatica is a term that is commonly used to describe the pain an individual has radiating down an extremity. Patients will come to the office with complaints of severe pain down one leg or, less commonly, down both legs. The term is often overused and not all cases of self-diagnosed “sciatica” are actually correct.

sciatic anatomy

Sciatic nerve anatomy.

The sciatic nerve is the largest nerve in the lower body. It is made up of multiple nerve roots that originate in the low back, the lumbar spine and sacral spine. These nerve roots join together within the pelvis and form the sciatic nerve.   This nerve then travels down the back of the leg innervating the muscles and providing sensation to the leg.

Sciatica is typically the term used to describe pain that one experiences in a leg, however, there is usually numbness or tingling and possibly weakness occurring as well.  As stated previously, the sciatic nerve provides innervation to multiple muscles in the leg and also sensation to specific locations of the leg. Thus, if there is enough dysfunction within the sciatic nerve, the person could very well experience more than just pain.

graphic disc herniation

A bulging disc pressed on the sciatic nerve.

The most common cause of sciatica pain is compression of one of the nerve roots that makes up the sciatic nerve. This compression is usually in the form of a disc herniation in the lower lumbar spine, typically, at the L4 – L5 disc or the L5 – S1 disc. These herniations protrude into the spinal canal and compress the nerve roots before they exit the spine and travel into the pelvis.  This compression of the nerve root will then initiate an inflammatory reaction. The nerve will swell, and the patient will experience immediate pain. As the inflammation grows, the pain will become more intense. Thus, the source of the pain is usually in a nerve root before it actually combines to help form the actual sciatic nerve.

Another group of people will experience sciatica pain not as a result of an acute disc herniation, but rather a chronic condition called disc degeneration.  These people are often older, and the pain may develop more slowly. The degenerative condition will cause collapse and bulging of the disc and ultimately result in a gradual narrowing of the spinal canal. The specific location of this narrowing is within the lateral recess, or the periphery of the canal. As this narrowing becomes more severe, the nerve root or roots will become compressed within the canal.  Again, the inflammatory cascade is initiated, causing the nerve to swell and pain to occur.

There are a variety of ways to treat sciatica, and the treatment depends on the cause.  A thorough physical exam needs to be performed in order to help determine the diagnosis. Typically, the treatment is initiated with a regimen of oral medications.  These medications can include non-steroidal medication, muscle relaxers and pain medications. In some cases, an oral dose of steroids is provided. In addition to medication, activity modifications are commonly required. The patient will receive instructions to refrain from any strenuous activities, including work related-activities and some hobbies.

If symptoms are poorly controlled with limited activity and/or medication, symptoms are worsening, or a physical exam warrants next steps, an MRI of the lumbar spine will be required. The timing of this MRI is somewhat controversial, because a significant number of sciatica cases will actually resolve with these simple treatments and time.  Those patients who experience symptoms and who do not respond to medication and rest may require further diagnostic workup. An MRI is always needed in the face of progressive weakness.

Typically, every effort should be given to first pursue the least invasive options. However, once a successful MRI has been obtained, another set of treatment options becomes available, including epidural steroid injections and possible surgical interventions. The epidural steroid injection is often times the first line of treatment for patients who do not get resolution with medications and activity modifications.  Epidural steroid injections are common and place steroid solution at the nerve root responsible for the pain symptoms. They are performed in a operating room with the use of X-Ray. The actual technique can often be performed in a matter of minutes, and they are low risk compared to other treatment options. Up to three injections can be performed in a twelve month period. Injections are a great option for those patients that do not wish to pursue a surgical option or individuals with medical problems that preclude a surgical procedure.

The last option for a patient with sciatic pain would be surgical intervention, and can be accomplished with minimally invasive techniques. The mainstay of surgical treatment for both disc herniation and/or a degenerative bone spur will involve a laminotomy. A laminotomy is a surgical procedure that involves removal of a small portion of the bone. It is a safe procedure, and the most common procedure performed on the spine. There are minimally invasive techniques that can be utilized that can decrease the pain associated with the procedure and offer quicker recoveries.

A patient with a disc herniation will undergo a laminotomy and removal of the disc herniation. Again, this surgery is done as an outpatient procedure—meaning the patient will not need to stay in the hospital. Typically, patients do not receive any formal physical therapy after the procedure. However, they are commonly restricted in their activities for a total of six weeks postoperatively. These restrictions can include limitations as to the amount of weight they can pick up and avoidance of strenuous activities including repetitive bending, lifting and twisting. These restrictions are required to avoid another disc herniation from occurring. Surgical results are often very successful and predictable. Often times, patients will have some tingling in the extremity that improves with time, and usually experience almost complete relief of the pain in the extremity. Symptoms can fully resolve with time as the nerve heals.

Sciatic nerve pain is a very common and debilitating condition. However, with proper diagnostic workup, successful treatment is possible. Typically, treatment starts with nonsurgical options. However, if this approach is unsuccessful, epidural steroid injections and possibly surgery are often utilized to resolve symptoms and return the patient to a pain free lifestyle. If you are experiencing the symptoms explained in this article, please do not hesitate to call our office and schedule a consultation. Our physicians want you to live pain free and can help you get the relief you need.

This article was published in the April-June 2015 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.

Orthopaedic Surgery Center of Illinois Wins Prestigious Press Ganey Award

By Leo Ludwig, M.D.2014-guardianaward-hires

As the medical director of the Orthopaedic Surgery Center of Illinois (OSCI), it is my pleasure to present to you our yearly quality report card. OSCI is located across the street from the Orthopedic Center of Illinois in the Koke Mill Medical Center.

On a yearly basis, we evaluate our case types and volumes, certain quality reports, as well as patient satisfaction. This data is analyzed with the goal of providing our patients with the best quality outpatient experience and outcomes. The Affordable Care Act (Obamacare) is drastically changing the landscape of medical practice in the United States and is more closely monitoring healthcare facilities to provide the highest quality care at the lowest price. OSCI is excelling at this goal.

OSCI utilizes the nationally recognized Press Ganey satisfaction survey to measure patient satisfaction. I am proud to announce that OSCI, for the second year in a row, has been awarded the 2014 Press Ganey Guardian of Excellence Award. Press Ganey has more than 10,000 clients nationally and less than 5% received this award, which is given to healthcare facilities that rank above the 95th percentile in patient satisfaction for 12 consecutive months. OSCI is the only facility in Central Illinois to receive this designation. This award is a tribute to the care provided by the staff and physicians at OSCI.

osci graph

Click to enlarge.

More than 3,000 patients annually receive healthcare services at OSCI. As you can see in the graph, the most common surgical procedures performed are arthroscopic procedures of the knee and shoulder. Various hand surgeries, as well as fixation of bone fractures, are other common procedures. Newer procedures such as hip arthroscopy and outpatient spine surgery continue to grow in volume. Additionally, our pain management physicians are busy performing lumbar and cervical epidural steroid injections. In 2014, we began to offer cataract surgery and the program has been very successful with 225 cataract surgeries completed.

From a quality standpoint, 100% of the patients undergo a safe surgery checklist, 100% receive appropriate and timely antibiotics to help prevent infection, the complication rate is less than 1%, and the infection rate is less than 1%. In addition, the cost of providing care for these procedures at OSCI is significantly less expensive than the services provided in a hospital outpatient surgical department. As you can see, providing high quality care in a lower-cost facility is exactly what is necessary in today’s healthcare environment. If you, a family member, or friend requires one of these outpatient procedures, please talk with your physician about the possibility of having your procedure at OSCI.

LeoLudwig copyDr. Leo Ludwig is Medical Director at OSCI and a surgeon at the Orthopedic Center of Illinois. His special areas of interest are shoulder surgery, arthroscopic surgery of the shoulder and knee, and minimally invasive total joint replacement.

We’re Here to Help You in 2015: Sports Medicine to Weight Loss

RonRomanelli copyBy Ron Romanelli, MD

If you made health resolutions for personal improvement in 2015, we are committed to helping you reach your goals. Whether you are injured, in need of surgery, or are on the road to recovery from surgery, our skilled team of surgeons and staff are here to serve you.

While we provide quality care for these challenges, we recognize that our commitment to your musculoskeletal health extends far beyond surgical care. Improving fitness and weight loss is an important part of the equation for healthy bones and joints. At Midwest Rehab, we offer individual and group fitness classes to build strength and jump start weight loss. Whether you are already familiar with working out or if you are just a beginner, we modify our programs to accommodate your skill level. Call today to schedule a free consultation: (217) 547-9108.

Sports are an important part of fitness, one that physicians here at OCI enjoy and are committed to. As the sports medicine physicians for both Memorial SportsCare and St. John’s AthletiCare, we are here for you no matter what the injury. Many of our physicians on staff are athletes themselves, and we know what it takes to make a full recovery to get you back in the game. Let us make the assist, please feel free to call us 24/7 for all of your sports strength and rehabilitation needs: (217)-547-9100.

If you have been living with pain, resolve to be pain free in 2015. We have an incredible team of specialists who are ready and willing to address any and all of your musculoskeletal issues from head to toe. Through national continuing education, we remain leaders in the field of minimally invasive treatments, providing advanced, cutting-edge care in the comfort of our community. This team has been helping patients with their pain for 40 years now, and can’t wait to serve you. We are always “on call” for you!

NEW DATE! Community Education: “Improving Outcomes for Hip and Knee Replacements”

GordonAllan-rounded-wb copyIn the past several years, changes to techniques used for hip and knee surgery have reduced postoperative pain and recovery time dramatically. Join Dr. Allan to learn how computer assisted surgery, medicinal changes in pain and inflammation control, preoperative health and more contribute to better outcomes following joint surgery.

Wednesday, February 18 • 6:00-7:00 p.m.

Prairie Heart Institute at St. John’s Hospital
Dove Conference Center
619 E. Mason, Springfield

Light refreshments provided. Reserve your seat today! Call (217) 814-4308.