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.

Practice Caution with Heavy Luggage this Summer

From the American Academy of Orthopedic Surgeons

Carrying heavy luggage during summer travel can be brutal on bones and joints, so whether traveling by plane, train or automobile, know your limits and practice safety first.

According to the U.S. Consumer Product Safety Commission (CPSC), there were 75,543 luggage related injuries in 2013, an increase of more than 20,000 when compared to 2012.

While many of the injuries associated with carrying heavy luggage are minor, they can be painful and can take several days or even weeks to recover. Travelers can avoid common neck, back and shoulder strains and other injuries altogether by cautiously handling their luggage.

•When purchasing new luggage, look for a sturdy, light piece with wheels and a handle.luggage

•Pack lightly. When possible, pack items in a few smaller bags instead of one large luggage piece.Many airlines restrict carry-on luggage weighing more than 40 pounds.

•When lifting luggage onto a platform or into a car trunk, stand alongside of it, bend at your knees, not your waist, lift with your leg muscles, then grasp the handle and straighten up. Once you have lifted your luggage, hold it close to your body.

•When placing luggage in an overhead compartment, first lift it onto the top of the seat. Then, place your hands on the left and right sides of the suitcase and lift it up. If your luggage has wheels, make sure the wheel-side is set in the compartment first. Once wheels are inside, put one hand on the luggage and push it to the back of the compartment.

•Do not twist your body when lifting and carrying luggage. Instead, point your toes in the direction you are headed, and then turn your entire body in that direction.

•Do not rush when lifting or carrying a suitcase. If it is too heavy or an awkward shape, get help.

•Do not carry heavier pieces of luggage for long periods of time. If it is too heavy, make sure to check luggage when traveling rather than carrying it on a plane, train or bus.

•If using a backpack, make sure it has two padded and adjustable shoulder straps. Choose one with several compartments to secure various-sized items. Slinging a backpack over one shoulder does not allow weight to be distributed evenly, which can cause muscle strain.

•Carry—don’t drag—your luggage when climbingthe stairs or, better yet, take the elevator with heavy luggage.

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

Advances in the Management of Sports Knee Injuries

By Rodney Herrin, M.D.
Board Certified Orthopedic Surgeon
Orthopedic Center of Illinois

Anterior Cruciate Ligament Injuries
There have been significant advances in the management of sports knee injuries, with the primary focus  on  attempting  to restore the normal anatomy. The anterior cruciate ligament is an important stabilizer of the knee. (See Figure A)A ACL picture  Once the ligament is injured, the knee may “give way “.  When this occurs, additional injury may occur to the knee including injury to the meniscus or the articular cartilage of the knee.  Therefore, often times when the anterior cruciate ligament is injured, surgical intervention is recommended. Anterior cruciate ligament reconstruction has evolved toward reconstruction of the ligament on an anatomic basis. A better understanding of the anatomy has helped with our reconstructive techniques and improvement in our surgical technology. By paying more attention to the anatomy we are able to improve the results for our patients.

When an anterior cruciate ligament reconstruction is being performed in the setting of a relatively acute injury, typically the attachment sites of the anterior cruciate ligament on the femoral and tibial sides are present.  These attachment sites can be used as references for reconstructing the anterior cruciate ligament.  In this setting, the center of the attachment sites of the anterior cruciate ligament can be marked with electrocautery.  The goal is then to try to place the tunnels for the reconstruction in those locations. The anterior cruciate ligament typically cannot be repaired and therefore must be reconstructed.  This may be done using either the patient’s own tissue (autogenous tissue) or using a donor tissue (allograft tissue). The autogenous graft options include the use of a bone patellar tendon bone graft, hamstring graft, or a quadriceps tendon graft.  The allograft options include bone patellar tendon bone, tibialis anterior, as well as Achilles tendon just to name a few.  Generally autogenous tissue is used in the younger athletes, which may help decrease the risk of re-injury.  As the patient matures, both autogenous or allograft tissue are reasonable options. Figure B demonstrates an anterior cruciate ligament reconstruction. The procedure is typically B ACL recondone arthroscopically.  There are a multitude of options for fixation of the grafts, the type of fixation used is partly dependent on the graft choice.  For example, a graft that has a bone plug attached to it, such as a bone patellar tendon bone graft, will typically use interference screws.  However, there are many acceptable options.

A current trend after anterior cruciate ligament reconstruction, is to proceed somewhat slowly when it comes to rehabilitation and returning  to sports.  It is felt that trying to return the athlete to their sport too rapidly may increase the risk of reinjury to the knee.

The meniscus is a fibrocartilaginous structure that helps protect the joint surfaces of the knee, and is commonly injured. We have learned that the more it can be preserved the better. Most commonly a torn meniscus is treated with a partial meniscectomy, preserving as much of the meniscus as possible. In some instances the meniscus is torn in such a way that the meniscus can be repaired. There many techniques that are available to help us with that task. The meniscus may be repaired with sutures that are C meniscal repairplaced from inside the knee to the outside of the knee.  This technique is still considered the gold standard, however there are many evolving techniques that are very helpful for meniscal repair.  These include techniques that are considered “all inside”, which has the advantage of being somewhat less invasive.  Figure C is an example of an “all inside” meniscal repair technique.

Meniscal Root Repair
Occasionally the meniscus is torn at its posterior root attachment.  Once that occurs, the meniscus is essentially rendered nonfunctional and no longer protects the knee as it is designed to do.  Repairing the meniscal root tear can be quite beneficial to the patient and the techniques to do so have significantly improved with the improvement of technology.  Essentially sutures are placed at the root of the meniscus and then a drill hole is placed in the area of the meniscal root attachment.  D meniscal root repairOnce that has been done, the sutures are pulled through the drill hole that has been made and the sutures are tied over a button. (See figure D)  This pulls the meniscus back to its anatomic attachment and restores the hoop stresses in the meniscus that protects the knee.

Meniscal Transplant
In certain circumstances, the meniscus cannot be preserved.  If a significant portion of the meniscus has been removed and the patient becomes symptomatic related to the absence of the meniscus, the patient may be a candidate for a meniscal allograft transplant. (See figure E)  To be a candidate, however, the patient needs to have E Meniscal transplant relatively normal articular cartilage and have satisfactory alignment of the lower extremity.  The procedure involves transplanting an appropriately sized donor meniscus into the knee of the patient.  The procedure is primarily done for improved symptoms and paint relief, but, is not typically performed with the goal of returning the patient to significant sporting type activities. It has not been proven that the meniscus transplant protects the knee from developing degenerative changes in the future.  The procedure can be technically demanding and does require obtaining the appropriately sized meniscal transplant.  In the appropriate patient however, it can be a reasonable option to consider.

Articular Cartilage Problems
The articular cartilage in the human knee has a limited blood supply and therefore, once injured, it cannot heal itself.  There are numerous ways to try to manage articular cartilage injuries and a great deal of research that is being done regarding treatment of these injuries.  The treatments can range from a technique known as microfracture to techniques such as autogenous chondrocyte implantation (ACI).  The technique of microfracture (See figure F) has been around for decades, but it is currently being F microfracturemodified to potentially help it be more successful. The technique of microfracture involves a process where the body fills the defect in the articular cartilage with fibrocartilage.  Although this is helpful to patients, the fibrocartilage is typically not as long lasting as normal hyaline articular cartilage.  Currently, the goal in management of articular cartilages problems is to develop cartilages more similar to hyaline articular cartilage, which is normally present in our knees.  Hopefully, this cartilage will be more durable and have longer benefit for the patient.  Methods that attempt to regenerateG ACI closer to normal articular cartilage include techniques such as Autogenous Chondrocyte Implanation (ACI).  This is a technique where the patient’s own articular cartilage cells are harvested and cultured and then re-implanted. (See figure G) Additionally, research into techniques that involve the use of stem cells, for example, may prove beneficial in the future.

Patellar Problems
Problems from the patellofemoral joint can come in several varieties  and may be related to patellar pain, patellar instability, or arthritis of the patella femoral joint.  Typically, patellofemoral pain in a patient with a normally aligned patellofemoral joint is managed nonoperatively.  Proper rehabilitation techniques, including strengthening of the core and pelvic musculature, as well as the quadriceps and hamstring musculature, can be helpful.

The problem of lateral patellar instability can be extremely disabling. Techniques continue to evolve toward restoration of normal anatomy and can be quite helpful to this group of patients. When a patella dislocates, often times the medial restraining structures become injured and may result in the patella becoming chronically unstable.   These injured structures can be addressed in the form of a medial patellofemoral ligament reconstruction.H  mpfl (See figure H)  Essentially, this technique uses tissues to reconstruct the medial patellofemoral ligament, which acts as a restraint from having the patella dislocate laterally.  Additionally, care must be taken to make certain that the distal portion or “pull” on the patella is aligned properly as well.  If alignment is found to be problematic, then realignment of the distal portion of the patella with a tibial tubercle osteotomy may be indicated as well to allow for proper “pull” on the patella. If there are problems with alignment of the patellofemoral joint, then all contributing factors should be addressed.  By stabilizing the patellofemoral joint, the patient then can often times be much more active and have a knee that feels more reliable.

The alignment of the knee is very important for proper function of the knee and that principle applies should any sort of reconstructive procedure be needed, as well.  Typically the weight bearing axis of the knee passes from the center of the hip, to the center of the knee, and down to the center of the ankle.  If the knee is malaligned, there will be increased force and potentially increased wear through the compartment where the alignment is passing through.  A malaligned knee would be a contraindication to the procedure such as an articular cartilage restoration procedure or a potential meniscal allograft.  Fortunately, there are techniques that have assisted in making the osteotomy more reproducible and also decreasing the morbidity of the procedure. These procedures can be done by either a closing wedge technique or an opening wedgeI Opening wedge HTO technique, but the tendency appears to be more for the opening wedge technique. (See figure I)  Additionally, the procedure can be done in the young active patient to try to help preserve the knee rather than perform an arthroplasty (replacement) of the knee.  For example, if the patient has significant wear and symptoms coming from the medial compartment of the knee, an osteotomy can be performed that allows for the alignment to be transferred to the more normal lateral compartment of the knee.  This can allow the patient to remain active in activities without concerns over the arthroplasty loosening or wearing out.  It is another technique in the armamentarium of orthopedic surgeons practicing the technique of joint preservation surgery. As our technology for fixation and alignment has improved it has helped with our patients outcomes and potentially has decreased the risk of complications.

When performing a surgery the surgical technique is extremely important, however just as important, is the proper postoperative rehabilitation.  Advancement is occurring in and a great deal of research is going on in the area of orthopedic rehabilitation. For example, we have learned that in patients with patellofemoral joint problems, strengthening the muscles of the core and pelvis is just as important ,if not more so, than strengthening the muscles about the knee. Additionally, we have learned that going a little slower with rehabilitation after an anterior cruciate ligament reconstruction may decrease the risk of reinjure.

In summary, the techniques to manage sports knee injuries continues to evolve and improve.  It is an exciting area of orthopedics.  At the orthopedic Center of Illinois, our board certified physicians are dedicated to keeping up with the latest techniques to allow us to provide our patients with the best current orthopedic and sports medicine care.

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

Solutions for Pain from Pedaling

By Theresa Delvo, Physical Therapist
Director of Therapy, Midwest Rehab at OCI

MWR PhotoThe snow has melted, the temperatures are rising and many of us are ready to get on our bikes and go for a long ride. Whether you’re an experienced cyclist, or just going out for a leisurely ride, below are a few hints in preventing injuries while riding.

Bike Fit

  • Keep a controlled but relaxed grip of the handlebars.
  • Change your hand position on the handlebars frequently for upper body comfort.
  • When pedaling, your knee should be slightly bent at the bottom of the pedal stroke.
  • Avoid rocking your hips while pedaling

Patellofemoral pain syndrome (PFPS)
One of the most common types of injuries particularly among athletes, active teenagers, and older adults is Patellofemoral pain syndrome (PFPS), which refers to pain at the front of the knee, in and around the kneecap or patella. It often occurs in people who are physically active or who have suddenly increased their level of activity, especially when that activity involves repeated knee motion– running, stair climbing, squatting, and cycling.

Patellofemoral pain affects more women than men and accounts for 20%-25% of all reported knee pain. Current research indicates the PFPS is an “overuse syndrome,” which means that it may result from repetitive or excessive use of the knee. Other contributing causes may include weakness, tightness, or stiffness in the muscles around the knee and/or an abnormality in the way the lower leg lines up with the hip, knee, and foot.

These conditions can interfere with the ability of the patella to glide smoothly on the femur (the bone that connects the knee to the hip) during movement. The friction between the under-surface of the patella and the femur causes the pain and irritation commonly seen in PFPS. Usually, patellofemoral pain is worse when you walk up or down hills or stairs and on uneven surfaces. This pain tends to increase with activity and improve with rest.

Common Problems
Anterior (Front) Knee Pain: Possible causes are having a seat or saddle that is too low, pedaling at a low cadence (speed), using your quadriceps muscles too much in pedaling, misaligned bicycle cleat for those who use clipless pedals, and muscle imbalance in your legs (strong quadriceps and weak hamstrings).

  • Neck Pain: Possible causes include poor handlebar or saddle position. A poorly placed handlebar might be too low, at too great a reach, or at too short a reach. A saddle with excessive downward tilt can be a source of neck pain.
  • Lower Back Pain: Possible causes include inflexible hamstrings, low cadence, using your quadriceps muscles too much in pedaling, poor back strength, and too-long or too-low handlebars.
  • Hamstring Tendinitis: Possible causes are inflexible hamstrings, high saddle, misaligned bicycle cleat, and poor hamstring strength.
  • Hand Numbness or Pain: Possible causes are short-reach handlebars, poorly placed brake levers, and a downward tilt of the saddle.
  • Foot Numbness or Pain: Possible causes are using quadriceps muscles too much in pedaling, low cadence, faulty foot mechanics, and misaligned bicycle cleat.
  • Iliotibial Band Syndrome (ITBS): Possible causes are too-high saddle, leg length difference, and misaligned bicycle cleat for those who use clipless pedals.

How a Physical Therapist Can Help
Your physical therapist will perform a series of tests to evaluate the knee, check flexibility of the muscles in your leg, observe the alignment of your feet, analyze your walking patterns and test the strength of your hip, thigh and core muscles to find out if there is a weakness or imbalance that might be contributing to your pain. After performing a series of tests to evaluate the knee, your PT will analyze, and prescribe an exercise program just for you.

Your individual program may include:

  • Strengthening exercises targeted at the hip (specifically, the abductor and rotator muscles of the buttock and thigh), the knee (specifically, the quadriceps femoris muscle, which is located on the front of your thigh and straightens your knee), the ankle and core.
  • Stretching exercises for the muscles of the hip, knee, and ankle.
  • Taping of the patella to reduce pain and retrain muscles to work efficiently.
  • Exercises for improving your performance of activities that have become difficult for you.
  • If the alignment and position of your foot and arch appear to be contributing to your knee pain, they may suggest a special shoe insert called an orthosis. The orthosis can decrease the stress to your knee caused by excessive rotation or impact during walking and running.
  • Recommend that you apply ice or heat for relief

Your physical therapist will work with you to help you stay active and maintain your fitness level. You may need to modify your activity level or change your training activities until you recover; your therapist will show you how to do activities and exercises that will not increase your pain. Most importantly, your therapist can make recommendations to help prevent PFPS from returning.

If you have any questions about the information in this article or would like to talk with a therapist about your exercise routine, we can help. Call Midwest Rehab today to set up a consultation: (217) 547-9108.

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!

Preventing Throwing Injuries

By Barry Werries, MD
Board Certified Orthopedic Surgeon

????????????????????????????????????????????????????????????????????Of all the athletic activities studied, throwing a ball creates one of the greatest forces across the elbow and shoulder. These repetitive forces make the shoulder and elbow susceptible to both acute and chronic overuse trauma. The incidence of baseball pitchers having shoulder or elbow pain is becoming an epidemic.

Even though the most common symptom is pain, there are other subtle signs and symptoms of an arm injury, such loss of strength and range of motion. The elbow or shoulder can have catching or locking or the player may have numbness in the arm. The player may have ball control problems or decrease in ball velocity. There may be changes in the mechanics which may actually cause damage somewhere else in the body. Other signs of fatigue may be an upright trunk or dropped elbow during pitching or increased time between pitches.

Risk factors for these injuries are the amount of pitching and pitching while fatigued. Other risk factors include pitching on multiple teams, pitching year round, playing catcher when not pitching, poor pitching mechanics, increased ball velocity, and poor physical conditioning. Injuries to the back or legs or loss of flexibility can alter the chain of events that contribute to the act of throwing and put more stress on the arm.

When a child who is not skeletally mature is exposed to throwing, the body will make some anatomic adaptations at the shoulder that may be protective. Although it is apparent that there should be a limit to the number of pitches to decrease injury, there may be an increased likelihood of injury in athletes who start pitching in high school than those who have been throwing in early childhood.


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Click to enlarge.

The USA Baseball Medical/Safety Advisory Committee has made recommendations on the limits of the number of pitches. Some organizations such as Little League Baseball have instituted these limits into their rules. These limits should also include pitches in practice, and coaches should be aware of pitch counts with players who play on other teams. Just as important as the number of pitches, the same committee has also made recommendations on days of rest after pitching. I am a firm believer that the body needs time to recover from the stresses of pitching, and I do not advocate throwing every day. Despite the emphasis on pitch count in a game, there is also evidence that the accumulation of pitches within a season is just as important to the health of the throwing arm. It is recommended to avoid any overhead throwing for 2-3 months per year and no competitive pitching for at least 4 months per year.

Unfortunately, little leaguers are throwing breaking balls at the age of 11 or 12. There has been a higher incidence of shoulder pain with curveballs and elbow pain with sliders. With proper mechanics, the curveball may not put increased stress on the elbow. Many young pitchers, however, have difficulty with the proper technique to throw a curveball, so there should be more emphasis on throwing a changeup at a young age. A safe approach is to wait until the age of 14 to start throwing curveballs and the age of 16 for sliders.

Proper throwing mechanics are very important to preventing arm injuries. Even though a pitcher is successful in games, throwing with improper pitching technique is like an engine leaking oil; the arm will eventually break down. If a pitcher does not correct his mechanic flaws, then his injuries will recur despite even surgical repair. Thus, it is advisable to have a coach who is knowledgeable of the proper throwing mechanics to work with a pitcher.

A majority of the throwing injuries occur in the beginning of the season because the players have not built up their strength. An excellent program for strengthening the arm is the Thrower’s Ten Program which focuses on the rotator cuff, scapular stabilizers, and forearm muscles. Many of the throwers who have arm problems have scapular dyskinesia. Scapular dyskinesia is when the scapula or shoulder blade is moving abnormally which creates shoulder/arm dysfunction and injury.

Many athletes focus on arm strengthening but they ignore the core/trunk and lower body strength which accounts for more than 50 percent of the kinetic energy to throw a ball. Core trunk stabilization focuses on strengthening the spinal and pelvic stabilizers and abdominal musculature. Weakness of lower body muscles, especially the hip abductors and hamstrings, have been identified in athletes with shoulder and elbow injuries. It is also important to build up the endurance of the lower body, and I prefer an interval sprinting program over jogging for baseball players.

The loss of flexibility of particular joints in the throwing athlete will predispose them to arm injuries. In the shoulder, throwing athletes have the loss of internal or forward rotation which is addressed by stretching the posterior, or back, of the shoulder. Care should be taken when stretching the front of the shoulder because most overhead athletes have stretched out their anterior capsule, which is in the front of the shoulder. In the lower body and trunk, the lumbar (low back) inflexibility, hip rotation deficit and hamstring tightness can also increase the risk of arm injury. It is also recommended to stretch for 5 minutes after playing.

In summary, a pitcher should focus on proper throwing technique, good physical conditioning and flexibility, avoid excessive stress on the arm and allow the arm to recover from the stress of throwing will help decrease the chances of an arm injury.

This article was published in the October-December 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.

Enjoy the Great Outdoors Pain Free

By Joe Williams, Physical Therapist, Midwest Rehab at OCI

As the days begin to shorten and the air begins to cool,
Raking Exercisethe fall season also brings to mind the beauty of the changing leaves.  But, the leaves that are so pretty on the trees are not so beautiful on the ground.  Getting them off your lawn and out of your landscaping is a seasonal challenge that can be a challenge to your body as well.  We want you to protect your body.

Before heading out to work in the cool air, we have some suggestions to help protect you from injury.  It is always a good idea to do some type of warm up before jumping to a task in the yard.  The body needs some time to get going, the blood to start pumping, and the joints to loosen.  A 5-10 minute walk can be just the activity that can help get you going.

Now that the body is going, it is important to choose the right equipment.  Many hardware stores will sell you broad rakes that pick up a lot of leaves with one pass.  While this might seem desirable at first, the larger the rake, the larger the load you are lifting.  Consider how much force it might take you to lift those leaves to bag them.  Wet leaves will be heavier than dry ones, which will also increase the load you lift.  Rake heads may vary from 8″ to 30″ or more.

As you start to use the rake you have chosen, it is very important to watch your posture.  Raking is by nature an activity in which we flex the spine often.  This can create quite a strain on the back.  Try to keep the back upright and use your legs to step forward and back with the raking motion.  After 15 minutes of raking, it is also a good idea to stop and stretch.  After repeated flexing, it is good to extend the spine arching the back in the opposite direction.

Most of us prefer raking leaves on one side or the other.  But, that can produce uneven stresses on the back and other structures.  You would be wise to switch your grip on the handle often, switching the lead hand as you rake.

Many people live where they must bag their leaves.  Be sure to lift with your legs, keeping the back straight, when you are picking up the leaves.  Your legs can do the lifting when you keep the chest up.  Tightening the abdominals as you lift can help support the spine as well.  This can be a good time to practice good body mechanics, so it will be good habit with any other lifting you may do around your home or work.

Above all, be safe as you prepare your house and yard for the winter ahead.  Autumn is a great season, and we want you to enjoy it.  If you have questions about information in this article or would like to discuss how to prevent injuries with a physical therapist, we can help. Call Midwest Rehab today to set up a consultation: (217) 547-9108.

Jow Williams 4x6Joe received his bachelor’s degree from St. Louis University. He practiced in a wide range of settings before focusing on orthopedics. He is especially interested in treating lower back and lower extremity pain and other orthopedic conditions.

This article was published in the October-December 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.



Advances in Arthroscopic Management of Rotator Cuff Disease

By Ron Romanelli, M.D.

We all take for granted the complicated mechanics that allow our bodies to literally and figuratively move through our daily tasks. Only when we stop and reflect on this, do we realize the true complexity of our musculoskeletal system. Specifically, our shoulders enable us to perform various jobs, often not fully appreciated until an injury occurs. One of the most common injuries we see and treat at OCI is a rotator cuff tear.

The shoulder has a wider range of motion than any other joint in the body. This joint consists of an “O” ring around the shoulder socket, as well as a capsule and surrounding rotator cuff muscles. The rotator cuff is a group of four muscles and their corresponding tendons that wrap around the front, back and top of the shoulder joint.

The most common symptom of a rotator cuff problem is weakness or pain. Usually, it is described as general discomfort and is exacerbated with certain movements of the shoulder. Like many orthopedic conditions, the mechanics of rotator cuff problems can be separated into repetitive use injuries and traumatic injuries. Over time, repetitive use of the shoulder may wear out the tendon, and a rotator cuff tear can develop. Traumatic injuries, such as falling on an outstretched arm, can also cause rotator cuff tears.

As we age, overuse of our shoulders can cause several different issues, including tendinitis, impingement and rotator cuff tears. When tendons in the joint become irritated or damaged, we call it tendonitis. Impingement occurs when the fixed acromion bone on the top of the shoulder constantly rubs the rotator cuff resulting in shoulder aches and pains. Impingement syndrome can also develop into a rotator cuff tear.

A rotator cuff tear is diagnosed by listening to the patient’s history and completing a physical exam, as well as X-rays and an MRI. Typically, when evaluating patients, MRI scans are utilized not only to assess the size of the tear, but also assess the anatomy of the rotator cuff. Initially, we treat the problem with conservative management using medications, exercises and physical therapy with occasional cortisone injections. If conservative measures fail, surgical procedures for this problem become necessary. The most common reason for surgery is persistence of pain despite injections. When pain persists or weakness prevails, arthroscopic surgical techniques can typically give reliable pain-relieving outcomes.

Traditionally, surgeons used an open surgical technique to access the injury which involved a larger incision and splitting of the muscle. Now, most cases of shoulder surgery are treated with arthroscopy. Some time ago, our surgeons made the transition from open rotator cuff repair to arthroscopic rotator cuff repair after countless hours studying and refining techniques to provide the best leading-edge care to our patients. Not only can small repairs be done this way, but large rotator cuff repairs can be performed safely and effectively with excellent results.

The word arthroscopy comes from two Greek words: “arthro” (joint) and “skopein” (to look). It is a minimally invasive procedure which entails small incisions and small tubes called cannulas. During arthroscopic repair, the surgeon inserts a small camera called an arthroscope into the shoulder joint through the cannulas. The camera displays pictures on a video screen. These images are viewed to guide miniature surgical instruments and arthroscopic repair techniques. Arthroscopy allows us to diagnose the problem because we can see inside the joint, as well as examine the type of rotator cuff tear that is present, which enables us to deliver a more accurate surgical repair.

The current standard for arthroscopic repair involves special instruments that pass through the torn rotator cuff tissue, through the tendon and are anchored to the bone with sutures and knots. Another technique involves knotless sutures that tension the cuff to the bone. Both of these approaches avoid cutting muscles to access the damage, therefore requiring less pain and smaller cosmetic scars.

Arthroscopic surgery is performed on an outpatient basis using a light general anesthetic, as well as local anesthesia for patient comfort. Our surgeons at OCI also perform a shoulder block, or anesthetizing/numbing of the shoulder, so the patient does not have pain when they wake from the operation. OCI patients have excellent pain management results due in part to the anesthesia and shoulder block, in conjunction with a multi-modality utilization of medications. This means patients receive anti-inflammatory medications preoperatively, anti-nausea medications, and minimal narcotic medications, resulting in minimal pain postoperatively.

Advances in Arthroscopy
Through the years, arthroscopic surgery has been refined due to advances in technology which have created multiple ways to approach repair of rotator cuff tears. Companies have improved fixation methods, as well as the techniques to assist surgeons to give their patients the best outcomes. Current research is focused on sutures with growth factors and/or injectable agents to help with healing in difficult rotator cuff repairs.

We now have multiple options for bone anchors with sutures that are single loaded, double loaded, or triple loaded. Surgeons typically perform sliding knots and non-sliding knots in order to repair rotator cuff tears, but there are also knotless techniques. We select our tools and techniques specifically for each patient and their unique injury. Techniques include a single row or double row repair or a transosseous-equivalent repair. Special anchors allow us to not only suture the muscle down to the bony footprint of the rotator cuff, but also allows us to place sutures on the side, which is a double reinforcing type of repair. All of these options mean there is no one way to correct a rotator cuff injury.

We utilize early physical therapy to assure patients achieve their best outcomes. Tendon healing typically takes six weeks, during which
time we perform gentle, passive motion on the shoulder. The second phase is a strengthening program, typically from six to 12 weeks. It generally takes at least six months to a year to reach maximum medical improvement for the majority of rotator cuff tears. The patient, doctor and therapist work together as a team to achieve excellent results and eliminate pain and suffering related to rotator cuff problems.

Arthroscopic results are good to excellent for 95% of small tears, but as the tear progresses to a large size tear, the success rate decreases. Success is dependent on the age of the patient, the size of the tear, and the length of time the tear has been present. Often times, early evaluation and treatment are necessary for good results.

Neglecting a rotator cuff tear not only means declining surgical success rates, but patients experience arthropathy, an imbalance of the shoulder which can lead to secondary arthritis. This end-stage problem of a rotator cuff tear that is not fixed may lead to a need for a reverse shoulder replacement. Putting off treatment will only result in prolonging the discomfort, and over time, can create more damage. If you have shoulder pain, please contact us to set up an appointment with one of our talented surgeons to begin the diagnostic and, if necessary, treatment process.

This article was published in the July-September 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.

Advances in Hip and Knee Joint Replacement

By D. Gordon Allan, MD, FRCS(C)

Over the past several years, there have been many changes to techniques used for hip and knee replacement surgeries. Some changes have presented challenges, but many of the changes have reduced the length of hospital stay, postoperative pain and total recovery time. In this article I will outline some of these important changes and discuss how they impact patients.

minimalinvasive2-300x288Minimally Invasive Surgery
Several years ago, the term “minimally invasive surgery” was applied to joint replacement. I believe it was mostly a marketing tool to boost a surgeon’s case volume and complete in aggressive markets. There is hardly anything minimally invasive about a surgery that can produce life altering complications. The term “minimally invasive” was coined to reflect the use of a dramatically shorter incision during surgery, yet patients experienced new challenges do to the change in technique. Initially, negative outcomes included significantly longer surgeries and more complications (fractures, component malpositioning, poor fixation, etc.) that resulted in early failure and reoperation. We no longer measure success by striving to make very small incisions. However, length of incisions has decreased over time and there are many more important variables that hasten recovery and reduce discomfort.

Reduction of Inflammation
Both before and in the days after surgery, anti-inflammatory medicines are utilized. The use of Celebrex and Decadron (a steroid) help tremendously with postoperative pain. A recent study demonstrated that the use of Decadron before and the day after surgery decreased pain, narcotic use, nausea and length of hospital stay. Decadron is a cost-effective and well-known medicine.

Pain Control
It has been known for years that the avoidance of intravenous narcotics speeds recovery, reduces nausea and improves attendance at therapy sessions, hence promoting an earlier discharge. Despite this, many surgeons continue to use a PCA pump (patient controlled analgesia) in the mistaken belief that it is somehow beneficial to the patient.

Spinal anesthesia is preferred over a general anesthetic as there is much less nausea and confusion, plus there is no “hangover” feeling. Patients are more alert and ready to participate in therapy. Most times, particularly for knee surgery, a nerve block is done to provide hours of pain relief without the need for narcotics.

I use multimodality pain management that includes Celebrex, Decadron, intravenous acetaminophen (Tylenol), Tramadol (a synthetic opioid pain medicine), oxycontin (a long acting oral narcotic), Norco (a short acting oral narcotic) and a muscle relaxant. Intravenous morphine is reserved for intense, immobilizing pain. Combined with a nerve block, these patients are not over sedated. The different modalities are used synergistically to reduce pain while avoiding the sedative effects of high-dose intravenous narcotics.

This approach has greatly reduced my patient’s length of stay and most healthy individuals, with good help at home, can be discharged the day after joint replacement. In contrast to years ago, patients would routinely spend three nights in the hospital and many older patients would be discharged to a nursing home.

Blood Loss Reduction
Several years ago, patients would either predonate their own blood or have family members donate for them. This practice is not any safer than using banked blood and actually is more costly. Most of this blood was wasted, and this practice is no longer utilized.

Currently we use a medicine called tranexemic acid given intravenously during surgery. This drug reduces the body’s natural tendency to break down clotted blood and thereby reduces surgical and post operative blood loss. As a result, only a very small minority of total joint patients requires a blood transfusion.


Top: Total Knee Replacement
Bottom: Partial knee replacement

Partial Knee Replacement
Patients with osteoarthritis localized to one part of their knee may be candidates for partial knee replacement. The advantage of partial versus total replacement is that the recovery period is faster and the knee feels more normal. The cruciate ligaments are retained so motion, stability and nerve feedback is maintained. Patients with severe deformity or inflammatory arthritis (i.e. Rheumatoid arthritis) are not candidates. Alignment of partial knee replacement is crucial to their longevity. One way proper alignment can be achieved is with robotic assisted surgery.

Computer Navigated/Robotic Assisted Surgery
Computer navigated surgery has been around for years but has failed to demonstrate clear advantages in routine cases over traditional bone preparation for hip and knee replacement. This technique adds considerably to the operative time and expense. Occasionally, when there is significant bone deformity, surgical navigation can be a great assistance.

Recently, computer navigation has been merged with robotic assisted surgery. This technique known commercially as MAKOplasty® has been very effective in preparing the bone and assuring optimal alignment of partial knee replacement and cup placement in total hip replacement. I have been using this technique since 2012 and have been very pleased with the results.

Direct Anterior Approach for Total Hip Replacement
This approach is unique in that no muscles or tendons are cut and the posterior hip capsule is untouched. As a result, patients recover very rapidly, their hips are stable and they do not have to follow the usual posterior hip precautions. A special operative bed that helps with gaining access to the hip facilitates this surgery. Both Springfield hospitals have two of these beds. I have been doing this approach since 2008 and have done more than 600 cases in this fashion. Most patients leave the hospital the following day and are often free of walking aids within days. The direct anterior approach has radically changed my hip practice.

New Thoughts on Anticoagulation
For years, total joint patients were vigorously anticoagulated with blood thinners after surgery as surgeons feared blood clots could be fatal if they traveled to the lungs. We used such drugs as Coumadin or Heparin. Recently it has been found that we are actually causing more complications and expense with this approach. I now assess the individual risk of each patient for the development of clots and treat most patients less aggressively than in the past. As a result, they are experiencing less surgical bleeding and fewer infections.

Importance of High Surgical Volume
Many studies have demonstrated that surgeon and hospital volume play a very large roll in the complication rate of joint replacement surgery. The high volume creates very good data for objective outcomes. Each year, I complete more than 500 primary and revision joint surgeries, and both Springfield hospitals are high volume joint centers.

Metal on Metal Bearings
Some early failures of metal on metal total hip prostheses have been in the news over the past few years. The ASR cup by Depuy is the most well known of these implants. Not all metal on metal bearings will fail, but it is very important for these patients to have very close follow-up to detect bone and soft tissue damage before it becomes irreparable. These implants can fail from poor wear at the bearing surfaces, loosening of the cup and through corrosion at the junction of the metal ball and stem. Yearly exams along with X-rays are essential. If problems are suspected, a blood test to determine the level of Cobalt and Chromium can be done, and a specialized MRI can look for tissue destruction and fluid collection. If problems are encountered, a change of the bearings is required.

Life-Long Follow Up of Prosthetic Joints
All joint replacements need to be followed with periodic X-rays throughout the patient’s life. Bearings will wear very slowly over time and this can produce a reaction by the body against the foreign particles created by this wear. In turn, this can lead to destruction of the bone around the implants which, if allowed to go on unchecked, can result in the loosening of the implants or even fracturing of the bone. This could be a catastrophic event that may be very difficult to repair. Therefore, X-ray assessment is essential every few years. Often, the bearings can be changed out in a relatively minor surgery if wear is detected.

Antibiotics Prior to Dental Procedures
Dental procedures or other interventions can allow bacteria into the bloodstream; therefore, joint replacement patients are prescribed antibiotics prior to these procedures. While there is no clear consensus, most physicians would agree that patients should take antibiotics for two years following a joint replacement. I currently ask my patients to use antibiotics whenever they see the dentist, indefinitely.

Pre-Operative Assessment
We are now very focused on ensuring that our patients’ health is optimal prior to embarking on elective joint replacement. We ask that our diabetic patients have excellent control of their sugars, and we decline surgery until their hemoglobin A1C is less than 7. We ask smokers to quit several weeks prior to surgery. We test everyone for Methicillin Resistant Staphylococcus Aureus (MRSA), and those who test positive receive treatment before surgery and a different antibiotic during surgery. We also test for malnutrition (protein level in blood) and vitamin D deficiency, which are corrected prior to surgery. Very obese patients are at risk for many complications, foremost of which are infection and implant malpositioning. We typically ask that patients reduce their body mass index (BMI) to less than 40 prior to surgery.

Although joint replacement surgery is largely a very successful and life-changing surgery, it should not be entered into without ensuring that the patients’ medical status is optimized and that a high volume, experienced surgeon and facility are selected. In doing so, the outcome should be maximized and the risk of complications minimized.

For more information about the services discussed in this article, or to schedule an appointment, call (217) 547-9100.

This article was published in the April-June 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.

Staying Balanced: What Keeps You on Your Feet

By Amy Blanford, PT, DPT
Midwest Rehab at OCI

balanceWhat are YOU afraid of? For those with balance problems, fear of falling is a very real and scary problem. Emergency rooms nationwide treat a patient every 15 seconds for a fall related injury (most of whom are in the 65+ age range). These falls frequently result in injuries that can have a lifelong impact. For those who fracture a hip, 20% end in death within the next year.

Balance is a very complex series of constant adjustments that help us stay upright. There are three systems that work together to maintain balance. Vision, sensory input from the legs and feet and the vestibular system of the inner ear all function in tandem to allow adaptation for changes.

The eyes help us stay oriented to the horizon ahead. When vision is impaired or if we have to function in the dark, the brain has decreased input to process for balance. As an example, if a person stands with their eyes open, it is usually easy to maintain quiet stance with no wobbling. If the same person closes their eyes and tries to stand quietly for 20-30 seconds, they will sense their body swaying slightly to try to adjust balance without visual input.

Sensory information from the legs and feet is critical for adjusting to changes in surface. Walking on a firm, flat concrete driveway is fairly simple. Crossing the yard requires constant alterations in balance to accommodate the bumps, slopes and holes that are common. If the sensation from the feet is impaired, the brain does not get clear messages about the surface under the feet. Sensation from the feet can decrease due to problems such as peripheral neuropathy, back problems and diabetes. Weakness in the lower extremities can also slow or decrease the balance reactions. Strengthening and proprioceptive training in physical therapy can help improve awareness and reaction time for the legs.

The vestibular system is located in the inner ear. Its primary job is to send information to the brain about where our head is positioned in relation to both the body and the ground. As we move our head, the vestibular system provides information about current position. During transitions from lying down to sitting, the inner ear is responsible for sensing when the body is erect. This prevents tipping over from sitting or overshooting the desired upright position. Conditions in which this system does not function correctly can cause dizziness with positional changes or head movements.

The staff at Midwest Rehab are trained to work with patients who have balance and dizziness problems for a variety of reasons. Often times treatment techniques include strengthening and stretching for the lower extremities. Balance and proprioceptive exercises help improve awareness of sensation from the feet and improved reactions to correct missteps and changes in the surface under the feet. Vestibular exercises and treatment can decrease dizziness with changes of position and head movements. Physical therapy can help to address balance and dizziness issues. So, don’t get scared, get STEADY with help from Midwest Rehab’s physical therapy staff.

Learn more about Midwest Rehab at or call (217) 547-9108 today to schedule an appointment with a therapist.

This article was published in the January-March 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.