Category Archives: Conditions and Treatments

Total Hip Replacement Surgery

When a hip has been severely damaged or worn down by arthritis or a serious hip injury, hip replacement surgery can allow many people whose movement is disabled become more active. Total hip replacement surgery, also called total hip arthroplasty, is a surgical procedure during which damaged bone and joint tissue are removed and then replaced with new, artificial parts. The goal is to improve mobility by relieving pain and improving function of the hip joint.

What causes the hip joint to become damaged?
The most common cause of chronic hip pain and disability is arthritis.

  • Osteoarthritis occurs when the cartilage cushioning the bones of the hip wears away and the bones rub directly against each other, causing pain and stiffness.
  • Rheumatoid arthritis is a chronic inflammatory disease that causes joint pain, stiffness, and swelling.
  • Post-traumatic arthritis follows a serious hip injury or fracture when the bone and cartilage do not heal properly. The irregularities lead to more wear on the joint surfaces.

Breakdown of the hip joint can also occur when bones become damaged by an injury, tumors or insufficient blood supply.

Who is a candidate for hip replacement surgery?
The decision to have total hip replacement surgery is a joint one made by the patient, the patient’s primary care doctor, the patient’s family and an orthopaedic surgeon. Recommendations for surgery are based on the extent the patient’s pain, disability and total health status.

Patients may benefit from hip replacement surgery if

  • their pain limits everyday activities, such as walking, bending, getting out of a chair, going up stairs, getting off the toilet or getting up from the floor.
  • they are unable to sleep at night because of the pain.
  • they receive little relief from non-surgical treatments, such as physical therapy, exercise programs or anti-inflammatory drugs.
  • they suffer side effects from pain medications.

In the past, hip replacement surgery generally was reserved for people between the ages of 60 to 80 because they were less active and put less strain on an artificial hip. In recent years, however, the surgery is being used on younger people because new technology has improved the artificial parts, and the parts last longer and withstand more stress and strain.

What are the benefits of total hip replacement surgery?
Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and significant improvement in their ability to perform common activities. However, it’s important to know that the surgery will not enable someone to do more than he or she could before the hip problem developed.

How does hip replacement surgery work?
A joint is formed by the ends of two or more bones that are connected by thick bands of tissue called ligaments. The hip joint is located where the ball (femoral head) at the upper end of the femur (the long thigh bone) meets the rounded socket (acetabulum) in the pelvis. During the surgical procedure, the orthopaedic surgeon removes damaged cartilage and bone and replaces the ball of the femur and the pelvis socket with new, artificial joints. The surgical procedure generally takes 1 1/2 – 2 hours.

There are a variety of materials currently used in artificial hip joints. All of them consist of two main components: the ball component, which is made of highly polished metal, and the socket component, which is a durable plastic cup that may have an outer metal shell.

The surgeon uses one of three alternatives to secure the artificial hip joints:

  • In a cemented procedure, surgical cement is used to fill the gap between the prosthesis and the remaining natural bone to secure the artificial joint. Cemented procedures are more often used on older, less active people and on people with weakened bones, such as those who have osteoporosis.
  • In a non-cemented procedure, the artificial parts are made of porous material that allows the patient’s own bone to grow into the pores and hold the new parts in place. This form of surgery is often used on younger, more active people because it may last longer. The primary disadvantage of a non-cemented prosthesis is the longer recovery time and thigh pain that occurs as the natural bone grows and attaches to the prosthesis.
  • Sometimes a doctor may use a combination, or hybrid replacement in which a cemented ball and a non-cemented socket are used.

Soon after the surgery, sometimes even the day of the surgery, physical therapists teach a patient exercises to improve recovery. Usually within a day or two, patients are able to sit on the side of the bed and even walk with assistance. Full recovery from the surgery takes three to six months, depending on the type of surgery, the overall health of the patient, and the success of the rehabilitation.

In some cases, doctors are able to use special tools for a minimally invasive surgery when replacing the hip. Generally, recovery time is less and pain is lower when using this type of surgery.


A tendon is thick, fibrous cord that connects a muscle to a bone. Tendonitis is inflammation or irritation of a tendon. The condition, which causes pain and tenderness just outside a joint, is most common around shoulders, elbows, knees and ankles. It also occurs in hips and wrists. The pain can worsen if damage progresses because of continued use of the joint.

What causes tendonitis?

The most common cause of tendonitis is repetitive stress, or using the same joint for the same movement over and over. As a result, tendons, which normally are able to take lots of bending, stretching and twisting, become inflamed and painful. Tendonitis occurs in many sports that use repetitive movements. You often hear tendonitis referred to as jumper’s knee, golfer’s elbow or swimmer’s shoulder, for example. Tendonitis can also result from jobs that require repetitive movements. Construction workers, painters and factory workers are more likely to develop the problem.

The age-related wear and tear on tendons can cause tendonitis, too, as muscles and tendons lose their elasticity.

Some inflammatory diseases, such as rheumatoid arthritis, can lead to tendonitis pain.

The Spine

The spine, one of the most important of the structures in the body, allows a person to keep upright, stand, move about freely and bend. It also protects the spinal cord, which is made of millions of nerve fibers that connect the brain with the rest of the body.

Spinal Sections
The spinal column is divided into three main sections: the cervical (upper) spine, the thoracic (middle) spine, and the lumbar (lower) spine.

Cervical (Upper) Spine: This segment of the spinal column is made up of the first 7 vertebrae in the spine. It starts just below the skull at the top of the neck and ends just above the mid-back area. It is the most mobile section of the spine. The nerves of the cervical spine branch off to the upper chest and the arms.

Thoracic (Middle) Spine: This segment of the spinal column, the middle part of the back, consists of 12 vertebrae that connect the ribs and form the part of the back wall of the ribcage area between the neck and the diaphragm. This part of the spine and body is structured in a way that limits the amount of spinal movement compared to the cervical or lumbar segments of the spine. The nerves of the thoracic spine branch off to the chest and abdomen.

Lumbar (Lower) Spine: This segment of the spinal column is often called the lower back. It usually consists of five vertebrae. At the base of the lumbar spine is the sacrum, a fusion of many bones that connects the spine to the pelvis. Sometimes one of the bones of the sacrum will form as a separate vertebra rather than being part of the sacrum. This sixth, or transitional, vertebra that some people have in their lumbar spine normally does not cause any problems. Because the lumbar spine is connected to the pelvis where most weight bearing and body movement takes place, some people seem more prone to lower back pain. The nerves of the lumbar spine region branch off to the legs, pelvis, bowel and bladder.

Parts of the Spine
The individual parts of the spine make it a complex mechanism. The spine consists of bones, called vertebrae, and ligaments and muscles that connect the bones to form the spinal column. Other structures of the spine include the intervertebral discs, facet joints, spinal cord, nerve roots, neural foraminae, paraspinal muscles and spinal segments.

The vertebrae are the 24 individual bones of the spine. The body of each vertebra is a large, round portion of bone, and each vertebra is attached to a bony ring. In essence, the vertebrae are stacked on top of each other, and their rings create a hollow tube to hold and protect the spinal cord.

Intervertebral Discs
Intervertebral discs are soft, gel-like cushions between the vertebrae. These discs absorb pressure and help keep the bones of the vertebrae from rubbing against each other.

Facet Joints
The joints of the spine, the facet joints, connect the vertebrae to each other and give the spine its flexibility. The two facet joints of each vertebra (one on each side) overlap with neighboring vertebra’s facet joints. Without these joints, the spine would not be able to bend or twist.

Spinal Cord and Nerve Roots
The spinal cord is a column of millions of nerve fibers that carry messages from the brain to the rest of the body. The nerves control the body’s organs and parts, and allow a person to control his or her muscles.

The nerve fibers of the spinal cord branch off in pairs, called nerve roots, at different places in the spine to connect to specific parts of the body. The nerves of the cervical spine go to and control the upper chest and the arms. The nerves of the thoracic spine go to and control the chest and abdomen. The nerves of the lumbar spine go to and control the legs, pelvis, bowel and bladder. Damage to the spinal cord can cause paralysis in certain areas of the body and not in others, depending on which nerve roots are affected.

Neural Foraminae
The neural foraminae are the small openings on each side of the vertebrae where the pairs of nerve roots exit the spinal column to connect to specific areas of the body.

Paraspinal Muscles
Paraspinal muscles are the many muscles next to the spine. They support the spine and cause the spine to move. Each muscle controls some part of the movement between the vertebrae and the rest of the body.

Spinal Segments
A spinal segment is a term given to an individual grouping of parts of the spine. One spinal segment consists of two vertebrae attached by ligaments, the disc between the vertebrae, the facet joints that connect the two vertebrae and the neural foraminae between the two vertebrae.

Spinal Stenosis

Spinal stenosis occurs when the spinal canal narrows, irritating the spinal cord and nerve roots of the spine. The spinal cord consists of millions of nerve fibers that connect the brain with the rest of the body. The nerve roots are the nerve fibers that branch off along the spinal cord and connect to specific parts of the body. If any of these structures are irritated or “pinched,” the result can be low back pain and pain in the legs, the most common sites of problems. In rare cases, spinal stenosis can affect the neck area and be crippling if not treated.

What causes spinal stenosis?

The spinal canal is formed by bony rings attached to the vertebrae. The body’s 24 vertebrae are essentially stacked on top of each other, and the bony rings form a hollow tube to hold and protect the spinal cord.

A narrowing of this tube, the spinal canal, is usually caused by an excessive growth of bone and/or tissue, reducing the size of the opening. The result is a “pinching” or irritation of the spinal column and/or the nerve roots of the spine.

There are several reasons that may lead to the spinal canal narrowing, including:

  • Age-related degeneration: Age-related degeneration, or wear and tear of the spine, is the most common reason for spinal stenosis. Age can cause thickened ligaments, bone spurs, enlargement of the joints that allow the spine to twist and bend, and bulging disc problems. Any of these conditions can narrow the spinal canal.
  • Certain diseases and conditions: One of the bone-related diseases that can cause narrowing of the spinal column is osteoarthritis of the spine. In this case, the joint cartilage of the spine is worn away and bony growths, or spurs, occur. Paget’s disease and fluorosis are two bone diseases that may soften the spinal bones or cause calcium deposits to form. Infections and tumors may also put pressure on the spinal column.
  • Heredity: Sometimes the spinal column is smaller than usual at birth and may cause difficulties, even for a younger person.
  • Trauma: A spinal injury or previous spinal surgery may cause swelling that puts pressure on the spinal nerves.

What are the symptoms of spinal stenosis?

Symptoms vary greatly, depending upon the position of or severity of the narrowing. The most common symptoms include:

  • Pain with walking or prolonged standing.
  • A feeling of heaviness, weakness or tiredness in the legs.
  • Numbness or tingling in the legs.

Frequently the symptoms of spinal stenosis disappear with rest or when sitting down. Even leaning or bending forward may relieve pressure on the nerves.

How is spinal stenosis treated?

Treatment is based on the severity of symptoms. Most cases of spinal stenosis are treated conservatively to control or lessen the symptoms.

Non-surgical options

Spinal stenosis is problem that generally responds well to non-surgical care. Treatments may include the following:

  • Medication: Over-the-counter pain relievers and anti-inflammatory medications, muscle relaxants, and some narcotic medications may be prescribed, depending upon the level of pain.
  • Physical therapy: Patients will often be taught exercises to strengthen the back and abdominal muscles and maintain flexibility of the spine. A patient also learns correct posture and body movements to reduce pressure on the spine.
  • Rest and slowed follow-on activity: In some cases, decreased activity or rest is prescribed followed by the gradual resumption of activities and eventually increased exercise.
  • Weight loss: In some cases, losing weight relieves stress on the spine.
  • Epidural Steroid Injection (ESI): This injection is used to help reduce severe pain and swelling in the spinal canal if other conservative treatments do not provide relief. The shots are given on an outpatient basis.

Surgical options

Although the majority of spinal stenosis problems do not require surgical intervention, sometimes the pain and resulting disability are so severe that back surgery is the only option. Surgery removes or adjusts damaged parts of the spine to restore spinal alignment and strength, and to alleviate pressure on the spinal column and nerves.

The traditional way of surgically treating spinal stenosis is to perform a decompressive laminectomy of the lumbar spine to make the tube of the spinal canal larger. In this procedure, an incision is made over the affected area of the spine. The surgeon then removes a section of bone, called the lamina, from the back of the spine. The surgeon may also have to remove a portion of the facet joints, the joints of the spine that connect vertebrae to each other and give the spine its flexibility. If the stability of the spine is affected by the removal of any of the spine’s components, the surgeon may include spinal fusion as part of the procedure. The surgeon then closes the incision.

The pain that occurs after surgery, as after any surgery, can be relieved with pain medication. Patients sometimes feel continued pain after the surgery. This pain normally lessens as the spine heals.

Most patients get up and walk the day after surgery under the guidance of medical personnel. The average hospital stay can be up to three days, depending upon individual circumstances.

A patient will be given specific instructions before leaving the hospital about wound care and which activities to avoid while the body heals from the surgery.

Spinal Fusion

Spinal fusion, or arthrodesis, is a surgical procedure that “welds” or fuses together two or more of the spine’s vertebrae to create a solid bone bridge between the bones. At the completion of surgery and healing, which takes place over several months to over a year, the two adjoining bones are fused and no motion takes place between them.

In spinal fusion, the goal is to stimulate the body’s natural bone growth processes and encourage bone growth between two adjacent vertebrae to create a solid area of bone. This creates stability between the vertebrae, strengthens the spine’s structures and eliminates movement that causes significant pain.

Spinal fusion may be performed by itself or in combination with other back surgery to relieve pressure on the spinal column and nerves.

When is spinal fusion used?

There are a variety of conditions that may lead a surgeon to perform spinal fusion, including:

  • Injuries to the vertebrae, including traumatic injury from accidents and compression fractures.
  • Scoliosis or other abnormal curvatures of the spine.
  • Slipped or herniated disc problems.
  • Spinal stenosis.
  • A weak or unstable spine caused by infections, disease or tumors.

What happens during spinal fusion surgery?

In the most common and preferable form of spinal fusion surgery, natural bone is used to stimulate the fusion. Supplementary bone–either from the elsewhere in the person’s body, such as the hip or pelvis, or from a bone bank–is grafted onto or attached to two existing separate spinal segments. Then the entire area is immobilized to allow the newly introduced bone and the existing bone structure to grow together, or fuse, eventually creating one continuous piece of bone.

Immobilization may be done internally using by implants such as metal rods, externally using bracing or casting, or by a combination of the two methods.

The surgery is performed while a patient is fully asleep under a general anesthesia. This major surgical procedure generally requires several hours.

What happens after spinal fusion surgery?

Because spinal fusion is a major surgical procedure, recovery generally takes longer than with other types of spine surgery.

Patients often have a several day hospital stay and must complete follow-on rehabilitation to rebuild strength and functioning in the back.

The spine needs to be kept in proper alignment following surgery, so patients normally wear a back brace or a cast. In addition, they are taught how to move, reposition, sit, stand and walk properly.

Depending upon individual health status and age, it may take several months for a patient to return to normal functioning. It can take six to nine months or longer for the bone fusion to be completed.

Are there drawbacks to spinal fusion surgery?

The primary drawback to spinal fusion surgery is that the fusion eliminates the natural movement between two vertebrae, limiting the person’s movement. As a result, patients may need to avoid certain lifting and twisting activities.

There are other risks associated with spinal surgery. A patient’s surgeon will discuss all the risks in detail before surgery is undertaken.

Slap Lesion

A superior labral anterior-posterior (SLAP) lesion is an injury to the part of the shoulder called the labrum. The labrum is the cuff of cartilage that extends the socket part of the shoulder blade to better accept the ball end of the arm bone.

A SLAP lesion is a tear that occurs where the tendon of the biceps muscle meets the labrum.

SLAP lesions are usually classified into one of four types:

  • A Type I tear is a fraying of the labrum.
  • A Type II tear is when the biceps tendon and labrum become detached from their bed on the socket joint.
  • A Type III tear is when the labrum has a flap of tissue hanging down into the joint.
  • A Type IV tear is when the labrum has a tear that extends into the biceps tendon.

What causes a SLAP lesion?

Injuries to the labrum are tears that can be caused by trauma or repetitive shoulder motion.

Trauma injuries:

  • A fall onto an outstretched arm or the shoulder.
  • A sudden pull to the shoulder, such as when tying to lift a heavy object.
  • A sudden upward motion, such as when pitching a ball or trying to stop a fall or slide.
  • A direct blow to the shoulder.

Repetitive shoulder motion injuries are often associated with sports injuries that occur from activities such as pitching a baseball, throwing a football or lifting weights.

What are the symptoms of a SLAP lesion?

There are several symptoms that might indicate a SLAP lesion injury. These include:

  • A catching sensation, clicking or locking in the shoulder.
  • Pain in the front or top of the shoulder.
  • Increased pain with movement, especially with overhead activities.
  • Decreased range of motion of the shoulder and arm.
  • Susceptibility to dislocation.

Determining if pain is caused by a SLAP lesion is sometimes difficult because the injury often does not show up well on normal MRI scans. However a MRI scan with dye placed into the shoulder is often helpful to diagnose a labral tear. Sometimes, though, an actual diagnosis is made at the time of surgery when the orthopaedic surgeon has an opportunity to look inside the shoulder, most often during an arthroscopic surgical procedure.

How is a SLAP lesion treated?
Once a diagnosis has been made, an orthopaedic surgeon recommends the best treatment option. There are both surgical and non-surgical options, although surgery is most often needed.

Non-surgical options

Some tears can be treated conservatively. Non-surgical treatment may include the following:

  • Avoidance of activities that worsen pain (overhead activity, heavy lifting, repetitive motions).
  • Anti-inflammatory medication.
  • Physical therapy to regain motion and strength.

Surgical options

Surgical diagnosis and repair of SLAP lesions is usually done with shoulder arthroscopy. Arthroscopic repair makes use of a fiberoptic scope connected to a video camera and small, specialized instruments. In this surgery, the scope and instruments are inserted into small puncture-type incisions rather than through a larger open incision.

The type of surgical repair depends upon the extent of damage found. Some possible fixes include the following:

  • Type I injury: The surgeon uses a shaver to remove, or debride, the fraying of the tissue or to prevent a small tear from worsening.
  • Type II injury: The loose part of the labrum and bicep is “tacked” down to the cup of the joint.
  • Type III injury: The flap of labrum tissue hanging down into the joint is either repaired or removed, depending upon the size of the flap.
  • Type IV injury: The labral tear will be removed and the biceps tendon repaired. The labrum and/or biceps tendon may also need to be reattached to the cup of the joint.

After surgery, the start of physical therapy rehabilitation is dependent upon the type of surgical repair. Rehabilitation of the shoulder may begin immediately for a debridement or may be delayed up to a month after a repair while the labrum or biceps heal.

The Shoulder

The shoulder is one of the most flexible of the body’s joints. The shoulder joint is what allows people to move their arms and, as a result, move their hands to where they need to be used. To be so flexible, the shoulder must have a wide range of movement. Unfortunately, this ability to move so freely means the shoulder joint is one of the less stable joints in the body.

The shoulder is a ball and socket joint. However, unlike other ball and socket joints in the body where the ball is nearly surrounded by the bone “cup” part of the joint, the ball end of the upper arm bone (humerus) instead rests in a shallow cup located on the end of the shoulder blade (scapula). A cuff of cartilage (labrum) forms an extended cup in which the ball end of the arm bone rests.

The entire shoulder joint is held in place by a complex arrangement of muscles, tendons and ligaments.

Some of these muscles and tendons form the shoulder’s rotator cuff, a group of four tendons and four muscles that work together and form a “cuff” over the upper end of the arm. The four muscles are the subscapularis, the supraspinatus, the infraspinatus and the teres minor. The muscles start on the shoulder blade (scapula) and are connected to the upper part of the arm bone (humerus) by the tendons that are attached directly into the bone. The rotator cuff helps a person raise and rotate the arm and stabilize the shoulder within the joint.

In addition, the shoulder joint has a subacromial bursa, a fluid-filled cushioning sac between the deltoid muscle, the curved section of bone that forms the top of the shoulder (acromion) and the rotator cuff.

When one of the elements of this complex joint is injured, worn down by overuse or simply out of balance, the result usually is shoulder pain.

Shoulder Impingement Syndrome

Shoulder impingement is one of the most common reason adults have shoulder pain. It occurs when certain structures of the shoulder–particularly the soft tissues of the rotator cuff and the lubricating sack (subacromial bursa) between the rotator cuff and the underside of the bone that is the top part of the shoulder (acromion)–within the shoulder are irritated or “pinched.” When it becomes a chronic condition, a patient is diagnosed with shoulder impingement syndrome. This syndrome may be accompanied by shoulder tendonitis and bursitis.

Who is likely to develop shoulder impingement syndrome?

This condition is commonly caused by overuse and can affect young people as well as older adults. Athletes who participate in sports that have repetitive overhead movements, such as swimmers, pitchers and tennis players, are susceptible to shoulder impingement. Also, adults who perform repetitive movements, such as lifting or overhead activities like weightlifting, painting, wallpaper hanging or construction work, can develop the problem.

What are the symptoms of shoulder impingement syndrome?

Usually, the symptoms associated with shoulder impingement syndrome begin mildly and increase over time. In its early stages, the achy pain goes away soon after or within a day after the activity is finished. However, as the syndrome progresses, the condition becomes chronic and any type of overhead activity, including something as simple as reaching up into a kitchen cabinet, can cause pain.

Shoulder impingement syndrome symptoms may include:

  • Pain and discomfort in the shoulder that is present both at rest and with activity, particularly when performing movements that require the arms to move above shoulder level. Often the pain is sudden with lifting and reaching movements, and sometimes the pain radiates from the front of the shoulder to the side of the arm.
  • Mild to moderate weakness, especially worse with overhead activity.
  • Local swelling and tenderness in the front of the shoulder.
  • Mild popping or crackling sensations in the shoulder.
  • Possible numbness or tingling in the hands.
  • Trouble finding a comfortable position for sleep.

How is shoulder impingement syndrome treated?

Non-surgical treatment
The initial and preferred treatment for shoulder impingement syndrome is non-surgical alternatives. They might include:

  • Rest and avoidance of overhead and repetitive activities.
  • Oral anti-inflammatory medications.
  • Cold therapy.
  • Ultrasound therapy to stimulate the tissues and improve blood flow.
  • Physical therapy, including stretching and strengthening exercises.
  • Steroid/cortisone injection.

Surgical treatment
If, after several weeks to several months, the non-surgical treatment options don’t help, an orthopaedic surgeon may recommend surgery. The goal of surgery for this syndrome is to remove the impingement and create more space for the rotator cuff. This allows the ball on the end of the upper arm bone to move freely so the arm can be lifted without pain. This form of surgery is called subacromial decompression or anterior acromioplasty.

Depending upon the surgeon’s preference and the injury, the surgery may take one of two forms: open or arthroscopic.

  • Open surgical repair requires a small incision in the front of the shoulder. In most cases, the front edge of the acromion is removed along with some of the bursal tissue to create space.
  • Arthroscopic repair makes use of a fiberoptic scope connected to a video camera and small, specialized instruments. The scope and instruments are inserted into small puncture-type incisions rather than through a larger, open incision. The surgeon then removes bone and soft tissue.

The arm may be immobilized after surgery for the initial healing process. Soon after, a physical rehabilitation program will be used to regain range of motion and strength in the shoulder and arm. It may take several months to rehabilitate the shoulder and have pain subside.

Rotator Cuff Tear

The rotator cuff is a group of four tendons and four muscles that work together and form a “cuff” over the upper end of the arm. The four muscles are the subscapularis, the supraspinatus, the infraspinatus and the teres minor. The muscles start on the shoulder blade (scapula) and are connected to the upper part of the arm bone (humerus) by the tendons that attach directly into the bone.

The rotator cuff helps a person raise and rotate the arm and stabilize the shoulder within the joint. A rotator cuff tear occurs most often when one or more of the tendons are torn. When this happens, a person usually suffers significant pain and weakness in the shoulder.

What causes the rotator cuff to become damaged?

Rotator cuff tears most often occur in adults over the age of 40 but also can happen in younger people. The injury can occur gradually or suddenly.

  • Chronic or degenerative rotator cuff tear: A chronic rotator cuff tear is most common. In this case, the rotator cuff injury develops gradually in people who have a history of shoulder pain and shoulder tendonitis. Eventually the tendon is worn to the point that eventually it just gives way. This chronic injury likely occurs when someone performs repetitive overhead work (painting, stocking shelves, sheetrock workers) or when someone is an athlete who uses repetitive arm motions (swimmer, pitcher, tennis player). It also occurs as people age. The natural wear and tear breaks down the strength and flexibility of the tendons.
  • Acute rotator cuff tear: An acute rotator cuff injury happens to those who have no history of shoulder pain. This may occur when a person tries to lift something that is too heavy, for example. When the tear occurs, the individual may experience immediate pain, a popping sound or snapping sensation and immediate arm weakness. This sudden rotator cuff tear also can occur in conjunction with another injury to the shoulder, such as a dislocation, a fall onto the shoulder or a fracture.

How is a rotator cuff tear treated?
Once a diagnosis has been made, an orthopedic surgeon recommends the best treatment option. There are both surgical and non-surgical options.

Non-surgical options
Not all rotator cuff tears need to be fixed with shoulder surgery as long as there is still reasonably good function and little pain. So possible therapies include:

  • avoidance of activities that worsen pain (overhead activity, heavy lifting, repetitive motions).
  • cold therapy.
  • anti-inflammatory medication.
  • steroid/cortisone injection.
  • physical therapy to regain motion, which normally includes exercises to strengthen the non-injured muscles of rotator cuff to help compensate for the injured muscle.

Surgical options
Some patients have tears that leave them with limited movement, weakness, and pain. Surgery may be the best option.

The main goal of surgery is to re-attach the healthy tendon of the torn rotator cuff muscle to the location on the arm bone from which it was torn. If the tendon cannot reach this spot with the arm at the side of the body, the surgeon will release the tendon from the surrounding tissues. If the rotator cuff is repairable, a groove or trough is fashioned in the normal attachment site for the cuff. Sutures bring the edge of the tendon into the groove where it normally attaches.

If the tendon still doesn’t reach the attachment site or the tendon itself is in poor condition, the re-attachment may not be possible and the cuff tear is deemed irreparable. In this situation, the useless tendon is cut out and the shoulder is again examined to assure smooth and full motion. In some cases, a cadaver tissue graft (allograft) can be used to span the gap and repair the tendon.

Whichever the case, the objective is to relieve shoulder pain, improve strength and increase the function of the shoulder.

Some possible surgical techniques include the following:

  • Debridement: A partial tear or a tear where there is not enough tendon or the tendon is in poor shape may only require a trimming or smoothing procedure called a debridement.
  • Smooth and Move: Another surgical technique that may be used when the tear is not able to be corrected is the “smooth and move” technique. This is when the upper surface of the rotator cuff and the arm bone are smoothed by the removal of scar tissue, bony protrusions and irregular tendons. The surgery is followed by immediate post-operative motion to prevent the reformation of scar tissue.
  • Acromioplasty: This procedure occurs when the surgeon makes an incision over the shoulder and detaches the deltoid muscle to gain access to the torn cuff. The surgeon then removes bone spurs from the underside of the top of the shoulder bone and attempts to reattach the tendon.

Depending upon the surgeon’s preference and the injury, the rotator cuff surgery may take one of three forms: open, mini-open or all arthroscopic.

  • Open surgical repair is required if the tear is large or complex or if additional reconstruction such as tendon transfer has to be done. In some severe cases when there is substantial trauma or arthritic degeneration, a shoulder replacement is an option.
  • Mini-open repair is possible using new techniques and instruments so that the incision for the surgery is considerably smaller than the incision of the open surgical repair.
  • Arthroscopic repair makes use of a fiberoptic scope connected to a video camera and small, specialized instruments. In this surgery, the scope and instruments are inserted into small puncture-type incisions rather than through a larger open incision.

It is important to know that surgery can improve the mechanics of the shoulder but cannot make the joint as good as it was before the tear. In addition, complete recovery may take several months and include extensive physical therapy.

Posterior Tibial Tendonitis and Tears

The posterior tibial tendon is one of the major supporting structures of the foot. It is a fibrous cord that starts in the calf muscles, stretches down behind the inside of the ankle and attaches to a bone in the middle of the foot. That bone, the navicular, is a key structure in the arch of the foot. The posterior tibial tendon has an important role because it helps keep the navicular in its proper place to hold up the foot’s arch, and it provides support as a person steps off the toes when walking. If this bone moves out of position because of tendon dysfunction, the arch begins to sag and disappear, and a flatfoot deformity can occur.

Posterior Tibal Tendonitis and Tears
Figure 1: Normal anatomy and arch as seen in this view of the left ankle from the medial side.

If the tendon simply becomes inflamed, a person likely will be diagnosed with posterior tibial tendonitis. In some occasions the tendon can actually tear. A posterior tibial tear is the most common reason for an adult’s flatfoot.

What causes posterior tibial tendonitis or tears?

Posterior tibial tendon problems can occur for a variety of reasons, including:

  • Overuse: Overuse symptoms occur after activities that use the tendon, such as walking, hiking or climbing stairs, especially when a person is not used to such activities.
  • Degeneration: Long-term wear and tear can lead to tendonitis or a tear.
  • Trauma: A traumatic injury to the tendon can occur with a blow to the inside of the ankle or with a twisting injury. This is more likely for athletes involved in sports such as basketball, soccer or hockey. Excessive force placed on the foot, such as running on a banked road or track, can cause problems, too.

Additional contributing factors may include:

Abnormal anatomy and falling arch as seen in this view of the left ankle from the medial side. Compare position of navicular bone in figure 1 with figure 2.
  • Being overweight, which stretches the tendon and makes it more prone to irritation and tears.
  • Having previous surgery or trauma to the foot.
  • Having had previous steroid injections.
  • Having certain pre-existing diseases, such as rheumatoid arthritis or diabetes mellitus, which makes a person more susceptible to problems.

What are the symptoms of posterior tibial tendonitis and tears?

In most cases, the symptoms of posterior tibial tendonitis develop gradually. When the tendon tears, the symptoms are more obvious. Symptoms may include the following:

  • Pain and swelling on the inside of the ankle.
  • Loss of the arch and the development of a flatfoot.
  • A rolling of the ankle and foot inwards.
  • Weakness pointing the toes inward toward the foot.
  • An inability to stand on the toes of the affected foot.
  • Tenderness over the midfoot, especially when under stress during activity.
  • Gradually developing pain on the outer side of the ankle or foot as the arch flattens even more.
  • A popping sound associated with pain on the inside of the ankle when the tendon is suddenly torn during an activity.

How are posterior tibial tendonitis and tears treated?

Without treatment, the flatfoot that eventually develops can become rigid and a permanent deformity may result. This leads to difficulty walking, arthritis and increased pain. Therefore, it is important to treat posterior tibial tendon problems as soon as possible. The treatment recommended depends upon the severity of the problems.

In the early stages, treatment may include:

  • Rest from activities that irritate the tendon.
  • Anti-inflammatory medications.
  • Immobilization of the foot with a walking cast or boot to prevent motion.
  • Orthotic devices that may include shoe inserts to support the heel and arch or even an ankle stirrup brace.
  • Physical therapy to rehabilitate the tendon and muscle following immobilization.

In more advanced stages, surgery is often required. Surgical options may include cleaning away and removing any inflamed tissue around the tendon, realigning the foot bones, fusing some of the bones together or transferring fibers from another healthy tendon to repair the damaged posterior tibial tendon. The orthopaedic surgeon may use just one of these options or a combination of them.

After surgery, a patient is required to wear a cast for at least six to eight weeks. An intensive physical therapy rehabilitation program is also required to strengthen the supporting muscles, increase flexibility and heal the tendon.