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Shoulder pain is the second most common type of pain reported by patients in the United States. The rotator cuff is a complicated structure consisting of four muscle groups that attach to the long bone that connects the shoulder to the elbow.
The muscles and their functions are as follows:
Supraspinatus – Holds the humerous in place and keeps upper arm stable. Also helps with lifting.
Infraspinatus – Main muscle that controls rotation and extension.
Teres Minor – The slim, narrow muscle in the rotator cuff; it assists with rotating the arm away from the body.
Subscapularis – Holds the upper arm bone to the shoulder blade and helps with rotation, holding the arm straight and out and lowering it
Injuries causing pain are common and these injuries usually fall into the following three categories:
Rotator cuff tear – often the result of the wear and tear of daily use.
Tendinitis – an inflammation or irritation of the tendon that attaches to the bone.
Bursitis – irritation of bursa (a small sac filled with fluid that protects the rotator cuff).
Tendinitis and bursitis can get better with nonsurgical treatment.
However, rotator cuff tears often require surgery if physical therapy and medications do not help.
Unfortunately, traditional rotator cuff repair procedures involve suturing tendon to bone and result in long rehabilitation, significant lifestyle changes, and variable outcomes. Which is why many people choose to forego surgery until pain is severe and mobility is significantly impaired. The catch 22 is that as rotator cuff disease progresses, it becomes increasingly difficult to repair.
However, there is a new approach called The Rotation Medical Rotator Cuff System that includes a collagen based bio-inductive implant about the size of a postage stamp. The implant is placed arthroscopically through a small incision over the location of the rotator cuff tendon that is injured. It is secured with small staples. The bio-inductive implant dissolves slowly during the healing process. As it dissolves, it induces growth of new tendon-like tissue, resulting in thicker tendons and replacement of tissue defects.
This technology can be used in earlier stages of rotator cuff disease to slow progression. It can also be used in conjunction with traditional repair procedures to improve tendon biology and decrease the chances of re-tearing the rotator cuff tendon.
The advantages are shorter rehabilitation, faster recovery, potential to prevent or slow down disease progression, and decreased risk of developing a second degenerative tear.
Brachial plexus injuries are among the most devastating injuries, causing significant loss of function and the ability to perform tasks of daily living and in the workplace. They often occur as a result of motorcycle accidents, industrial trauma, or a heavy fall with stretching of the neck.
Early diagnosis and treatment makes a huge difference in eventual outcome.
The brachial plexus is a complex group of nerves that come from the spinal cord in the neck and travel down the arm. These nerves control the muscles of the shoulder, elbow, wrist and hand, and provides feeling in the arms.
These nerves can be damaged by stretching, pressure or cutting. Stretching can occur when the head and neck are forced away from the shoulder, such as during a car accident or a fall off a ladder at work. If the force is severe enough, the nerves can tear out of the spinal cord in the neck. Pressure could occur from the crushing of the brachial plexus between the collarbone and first rib, which can happen during a fracture or dislocation. Swelling in this area from excessive bleeding or injured soft tissues can also cause an injury.
Minor brachial plexus injuries usually completely heal in several weeks, and other injuries are severe enough that they could cause permanent residuals such a loss of function and chronic pain. Early intervention and recent advances in microsurgical reconstruction have greatly improved outcomes.
The more severe injuries or those not caught right away may require reconstructive surgery. Nerve reconstructive surgery is ideally performed within the first 3-6 months after acute injury to permit optimal recovery, allowing time for the regenerating nerves to connect with paralyzed muscles before dense scarring develops. In injuries that occurred more than six months ago, new techniques have enabled surgeons to transfer working muscles with their blood and nerve supply from distant parts of the body, enabling lost elbow flexion and shoulder motion to return.
However, the recovery process is slow –measured in months and years rather than weeks and months. Muscle takes between 6-12 months to recover and then work toward the return of strength and mobility needs to be progressive. State-of-the-art techniques like electric stimulation, biofeedback and pool therapy may be employed to help with the recovery process.
Most brachial plexus injuries are extremely complex because of the myriad of nerves which control function and feeling in the arm. The outcome is generally dependent upon:
Looking at medical developments throughout the last three decades, there have been significant developments in the management of these injuries, which include a better understanding of the anatomy, advances in diagnostic modalities, incorporation of intra-operative nerve stimulation techniques and more liberal use of nerve grafts. Additionally, current microsurgical techniques have resulted in increased functionality of the upper plexus injuries. As research continues, we can expect to see less pain and disability associated with brachial plexus injuries.
Carpal tunnel syndrome (CTS), the most common entrapment neuropathy, is caused by chronic compression of the median nerve as it enters the carpal tunnel. In fact, it is thought that between 3%-6% of US adults have or will develop CTS. It normally develops between the ages of 45-64 years and the prevalence increases with age. It is more common in women than men. Carpal Tunnel Syndrome has been around for a long time; reports of CTS date back to the 1800’s.
Interestingly, after all this time there is still no consensus for a treatment plan for mild to moderate CTS. A 2007 Cochrane review found treating CTS with corticosteroid injections appears to have an unknown affect and effects appear to be temporary with no benefit beyond one month. This study also found two injections of corticosteroids did not provide any additional benefit over one injection. More recently research has indicated that the benefit may last up to 10 weeks, some studies showed up to one year, with less chance of surgical intervention at one year. The problem in studying CTS is it has a tendency to have spontaneous remissions, which may also be partially responsible for a high 20%-34% “Placebo Effect.” The Placebo Effect is a beneficial effect produced by a fake drug or treatment.
A new procedure using ultrasound-guided perineural injection of 5% dextrose (D5W) showed a significant reduction in pain and disability and improved electrophysiological responses. The procedure is still in the testing stages, but could prove to be a much more cost-effective approach to treating CTS. The minimally invasive injections can be performed in a doctor’s office resulting in virtually no recovery period, and a much quicker return to work and other activities of daily living.
A study was conducted to find out the prevalence and risk factors of a rotator cuff tear in the general population. The purpose was to clarify the true occurrence of rotator cuff tears regardless of the presence or absence of symptoms.
Study participants consisted of 683 people; 229 males and 454 females with a mean age of 57.9 years (age range was 22-87). Background factors were examined, physical examinations and ultrasonographic examinations on both shoulders.
Interestingly, 20.7% of the study participants had a rotator cuff tear and the frequency increased with age. 36% had a rotator cuff tear with symptoms and 16.9% had a rotator cuff tear but were asymptomatic.
In conclusion, 20.7% of 1,366 shoulders had full thickness rotator cuff tears in the general population. The risk factors included a history of trauma, dominant arm and age.
The subacromial bursa is a small fluid filled sac located at the top, outer aspect of the shoulder designed to reduce friction between the acromion and the tendon of the supraspinatus muscle. While elevating the arm, rotating the shoulder, lifting, pushing, pulling or lying on the shoulder forces are placed on the subacromial bursa. This can also occur with a direct impact or fall onto the point of the shoulder. Irritation and/or inflammation of the bursa can occur over time with repetitious movements or suddenly with a direct blow to the point of the shoulder or a fall onto the shoulder.
Symptoms include pain at the top, front, back or outer aspect of the shoulder, which can sometimes radiate into the upper arm as far as the elbow. Less severe cases may experience an ache or stiffness in the shoulder which increases with rest following activities that placed strain on the bursa. However, as the condition progresses symptoms may increase during the activity or sport.
Although the condition can be diagnosed through a thorough subjective and objective physical examination, an ultrasound is usually used to confirm the diagnosis. Further diagnostics such as x-ray, CT or MRI can assist in the diagnosis of other conditions which may be present and assess the severity of the condition.
Generally, Subacromial Bursitis can be treated conservatively beginning with rest to the shoulder and diligently performing exercises. Physical therapy using ultrasound and cryotherapy to reduce inflammation is also helpful. If that didn’t provide adequate pain relief, then steroid injections could be tried. Surgery is a “last resort” type of care in the form of an arthroscope to visualize and repair any damaged structures.
Subacromial bursitis often occurs in conjunction with other shoulder conditions such as rotator cuff tear, tendinopathy, shoulder impingement or shoulder instability. These are usually of slow onset because the result of repetitive activities at work, but subacromial bursitis can also come about acutely, for example as the result from a direct blow to the shoulder or a fall on the shoulder.
These types of injuries are slow to heal and for that reason can result in high treatment costs and increased employee missed time from work. Often whether or not the claimant heals completely or at all is subjective and the success of treatment falls strongly on the claimant’s compliance. This makes surveillance a great option in cases of high suspicion because if you catch your guy in the middle of 18 holes with no apparent shoulder problems, then you really have something!
Low back pain is an extremely common condition world-wide. In fact, regardless of cause it is the leading reason for job disability. One in ten persons experience it and for the majority the pain becomes chronic in nature. Research published in the journal of Pain Medicine has found that massage may provide lasting relief for chronic low back pain.
The study involved 104 people with chronic back pain who were referred by their doctors to licensed massage therapists. They attended 10 sessions over a 12 week period and the therapists used techniques customized to the individual, rather than all using the same technique. At the end of the study, more than 50% of participants reported improvement in their back pain. In fact, their scores on a standard screening test dropped below the threshold for disability. For many, their improvements lasted. More than three months following treatment, 75% reported that they still felt better.
While it is suggested that massage directly reduces inflammation in the muscles, more research is needed to figure out exactly how it works to reduce pain.
Reference: Real-World Massage Therapy Produces Meaningful Effectiveness Signal for Primary Care Patients with Chronic Low Back Pain: Results of a Repeated Measures Cohort Study, Pain Medicine, Volume 18, Issue 7, July 2017, Pages 1394-1405.
Chronic low back pain (CLBP) of a minimum three months duration is the second leading cause of disability worldwide; as such it represents a major welfare and economic problem. In the last 10 years, the incidence of CLBP has increased by more than 100% and continues to increase dramatically in the aging population. It is responsible for more global disability than any other health condition. So, whether you are processing worker’s compensation or personal injury claims, low back pain is a condition to be reckoned with.
A back injury in an already degenerating spine can create CLBP. How? Healthy disks have a gel-like substance inside of them that acts as a “shock-absorber,” but as disks degenerate, they shrink, making them less able to buffer against motion. As disks collapse, they begin to compress the spinal nerves that run through them. Additionally, when gel leaks out of a disk (herniation), it results in bulges that can compress nerves or the spinal cord itself.
Recent research has shown that people with disk degeneration have lower levels of a protein called SPARC (secreted protein acidic and cysteine rich). This protein regulates cell growth and binds calcium, and is responsible for several biological processes, namely bone development. It is believed that less SPARC results in accelerated rates of disk degeneration along with low back pain and radiating leg pain. Mice lacking SPARC had an increased number of nerve fibers that were supplying disks and areas around disks which could explain how disk degeneration causes back pain. Degenerating disks have been found to have high levels of NGF (nerve growth factor), which attracts pain-sensing fibers to the area, which increases the subject’s sensation of pain.
But, the most troubling discovery is that over time, chronic low back pain leads to changes in the dorsolateral prefrontal cortex (DLPFC) of the brain. This area of the brain is involved in higher order processes such as conscious decision making, reasoning, working memory, inhibition, as well as outcome prediction.
The good news is that recent test subjects who positively responded to treatment had a reversal of changes to the brain. Research is continuously providing new information concerning chronic low back pain. In fact, there are drug therapies designed to block NGF that are currently in clinical trials, and if proven successful will be a brand new way of treating pain not only for the back but other areas of the body as well.
For more detailed information go to: http://relief.news/deciphering-chronic-low-back-pain/ .
Thank you to our guest blogger, J. Jay Goodman, MD, General and Vascular Surgery. It is highly unlikely that the development of an abdominal wall hernia can be attributable to a single strenuous event. A specific type of abdominal wall hernia referred to as an epigastric hernia (fatty hernia of the linea alba) is defined as a fascial defect of the midline and represents a congenital defect in the fascia between the rectus abdominal musculature. These hernias must lay in the midline between the lower edge of the sternum (xiphoid) and the umbilicus. An umbilical hernia is a separate type of anatomic defect.
The linea alba is embryologically formed by the midline junction of the rectus abdominis sheaths. Epigastric hernias begin as small protrusions of preperitoneal lipomas. An epigastric hernia tends to have small defects (less than 2.0cm) and are difficult to palpate in an obese individual. The hernia can appear spontaneously, and many are asymptomatic. Pain may develop from entrapment of preperitoneal fat or the omentum.
Work activities do not affect the onset or progression of epigastric hernias. If preperitoneal fat or intraabdominal tissue enter these small defects, the pre-existing anatomic pathology may manifest itself. If the hernia strangulates during work activities and emergency surgery is needed, one should relate the emergency need for surgery to the work activity. The work activity does not cause the hernia defect and does not accelerate the deterioration of the hernia.
Once an epigastric has been identified regardless of symptoms, it should be repaired surgically so that a complex emergency repair is avoided.
Dr. Goodman is available to do IMEs in the Milwaukee and Fox Valley areas. Contact Medical Systems for more information or to schedule.
Guest Blogger: Dennis Brown, MD
On July 2, 2017, the prestigious “Journal of American Medical Association” (JAMA) published an authoritative medical study regarding radiofrequency denervation (ablation) procedures for chronic low back pain titled "Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain," which concluded "The findings do not support the use of radiofrequency denervation to treat chronic low back pain from these sources" (facet joints, sacroiliac joints or a combination of facet joints, sacroiliac joints, or intervertebral disks).
It is medically probable radiofrequency denervation is not medically reasonable or necessary for the treatment of chronic low back pain.
Reference: Johan N. S. Juch, MD; Esther T. Maas, PhD; Raymond W. J. G. Ostelo, PT, PhD, et l Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain The Mint Randomized Clinical Trials, JAMA. 2017;318(1): 68-91.doi:10.1001/jama.2017.7918
Lack of support is the most difficult and critical problem to address because it is often a major factor in an ALJ’s decision that an IME report was not credible. Unfortunately, not all doctors agree on what constitutes adequate support. Thus, the cover letter writer may receive an IME report and conclude that the expert did not support her answers sufficiently, but be faced with a headstrong expert who disagrees. Although difficult, this scenario can be overcome.
First, the IME vendor should work with the writer to explain to the expert the importance of citing relevant evidence, professional experience, and medical literature in the report. The IME vendor should be able to explain to the expert that a conclusory answer without any sort of explanation as to how and why the expert reached the conclusion will not pass muster with the “trier of fact” (ALJ). In truth, experts want to write effective, credible reports because they know that good reports generate more business opportunities. Thus, experts will often be receptive to requests to strengthen their conclusions if the evidence and literature supporting their opinion is obvious and available.
Second, the cover letter writer is typically the person who is most familiar with the claim being addressed, which puts the cover letter writer in the best position to point to the hard evidence and literature that supports the expert’s conclusions. While no IME vendor will tell an expert what to write or what evidence to use, the IME vendor should convey the writer’s concerns to the expert. This would include asking the expert to consider specific relevant evidence or literature in their answers. Ultimately what the cover letter writer and the expert consider to be important evidence may differ, but in cases where the expert’s answer is wholly unsupported they are likely to be receptive to requests to clarify or amplify if the cover letter writer can explain why the answer is problematic unless the expert provides additional support.
No IME vendor can guarantee a perfect report. However, we should expect responsive, consistent, and well-supported IME reports. In judging the report, we should not ask whether the report is favorable but instead whether the expert reached a reasonable and well-supported conclusion from the available evidence. If they did not, your IME vendor can and should work with you to repair deficiencies in the report. Ultimately, those requesting IME reports have the right to expect to receive a reasonable and credible report based on the evidence made available to the expert.
Do you have any ideas on how to strengthen the cover letter so these types of problems are minimized?