Shoulder Pain After Rotator Cuff Repair

Case Report:

40 y/o female with 3 year history of left shoulder pain who had undergone left rotator cuff repair came to our office for evaluation. 

She had been involved in a  rear-end motor vehicle accident 3 1/2 years prior.  When the drunk driver struck her car, she was looking over her shoulder.

Her pain was localized in her left lower neck and shoulder, constant in duration, 6/10 in severity and burning in character.  Aggravating factors included lifting, extension and rotation .  A sport’s medicine evaluation obtained a MRI of the left shoulder which was significant for a tear in the rotator cuff.  Surgical repair was performed along with extensive rehabilitation.  Unfortunately for this patient, her pain did not resolve.

Referred pain is pain that is perceived at a site distant from the injury’s origin.  A classic example is during a heart attack when a patient may feel pain in the arm, jaw os back rather than in the chest which is the site of injury.

Facet joints are articular joints in the posterior aspect of the cervical, thoracic and lumbar spine. 

The cervical facets are a common site of injury following motor vehicle injury.  The C5/6 and C6/7 cervical facet joint are the most common levels injured.  Each facet level has a distinct referral pattern was demonstrated below:

Injury to the C5/6 and C6/7 cervical facet typically results in pain in the lower neck and shoulder.  Diagnostic injection completely resolved this patient’ s pain.

Pain can arise from many different areas.  A thorough evaluation is essential which is the standard of care at the Centeno-Schultz Clinic.  Not all shoulder pain originates from the shoulder.

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Understanding Your MRI: Knee Meniscus

The meniscus is tough fibrocartilage between the thigh bone(femur) and shin( tibia).  There are two meniscus per knee: one on the inside (medial) and one on the outside(lateral).

The meniscus functions as a shock absorber and therefore is critical.

The meniscus is C-shaped.

In viewing an MRI it is important to understand the view:  frontal/side/ from the top or from the bottom.

When viewing the knee from the side, the meniscus are two dark triangles between the femur and tibia(outlined in red).

The meniscus is easily viewed from the front as demonstrated below.

There are non-operative options to repair meniscus injuries which include the use of the stem cell therapy.  The Regenexx procedure allow patients the opportunity to use their own mesenchymal stem cells to repair damaged knee tissue.

Regenerative Sciences Heads to South America

Regenerative Sciences, a Colorado based autologous mesenchymal stem cell therapy clinic focused on orthopedic applications, signed a licensing agreement with industry leader Stematix to bring the Regenexx procedure to various parts of South america.  From the press release:

David C. Bonner, Ph.D., Chairman and CEO of Stematix, said, “We at Stematix are excited to be working with Regenexx, the leaders in applied regenerative medicine for orthopedic. We anticipate that this cutting edge, proven treatment will provide needed care for many patients in clinics established in Latin America. We are working toward a first clinic in Argentina during 2010. The expertise and experience of Dr. Centeno and Dr. Schulz will be invaluable in establishing our clinic in Argentina, and we look forward to incorporating advances in the treatment methodology that the Regenexx clinic in Denver will lead. “

Another FDA Recall

Today the FDA recalled Synex II vertebral implants.  The implants were recalled because they pose an imminent  health hazard.  Six adverse event reports have been  filed to date which demonstrated moderate to severe loss of vertebral body replacement height. Other potential complications included neural injury, increased pain and need for reoperation/revision surgery. Synthes had a previous recall in Feb 2009.

In a press release Synthes advised: “that surgeons and hospitals in possession of the subject devices must stop implanting them immediately.”

Vertebral implants are utilized in lumbar spine surgery and were thought to have a potential advantage over conventional fusion techniques.

Vertebral Implant

Surgery is a one way door:  once undertaken one can only move forward.  Complications are part of the risks of surgery. Removal of the disc, which functions as a shock absorber, can result in pressure overload in adjacent levels thereby advancing the degenerative casade.

A non-surgical option for the treatment of lumbar disc disease is the use of your own stem cells.  Utilizing the Regenexx procedure, patients have had reduction in their back and leg pain.

Nip and Tuck of Meniscus: Advancing The Degenerative Cascade

The knee meniscus is tough fibrocartilage that is positioned between the thigh(femur) and shin bone(tibia).

Each knee has a two meniscus:   lateral and medial.  They are C shaped.

They function as a shock absorber protecting the delicate cartilage in your knee.

Arthroscopic view of knee

Injury can result in a meniscal tear.  There are several different types:  horizontal, radial, oblique and longitudinal.

Surgery is often recommended despite the fact that 60% of meniscal tears are not associated with pain.

Menisectomy is where a portion of the “damaged” meniscus is surgically removed.  While the “damaged” area is removed often patients fail to obtain significant pain relief.  Furthermore studies have demonstrated that menisectomies increase the rate of cartilage loss in the joint.  This make sense since by removing a portion of the shock absorber, the forces of daily living are transmitted to the delicate cartilage.  The cartilage was not intended to bear this increased stress and therefore starts to degenerate.

The use of your own stem cells is now an option for patients with meniscus tears and degenerative changes in the knee-joint.

Longus Colli: Unappreicated Yet Critical Neck Muscle

A patient returned today after 6 weeks of specialized physical therapy(Egoscue).  She is a changed woman with significant reduction in pain and increase in motion. She asked that I share her story.

History:  4 year history of neck and right shoulder pain after a motor vehicle accident in which she was struck on the driver’s side door by a motorist who elected to disregard a red light.  She had no prior history of neck or shoulder pain.

Pain was constant in duration, progressive in nature, 6/10 in severity, involves both right and left side of neck with radiations into the right shoulder and scapula.  Aggravating factors involved lifting and turning her neck.

Treatment to date had included physical therapy, steroid injections, large doses of narcotics and muscle relaxants, Botox injections and surgical evaluation who recommended an urgent two level fusion at C5/6 and C6/7.

Physical examination was striking.  Patient was wearing a soft cervical collar which she had worn for the last 2 years.  Upon removal, the patient was unable to keep her head up.  Her head, like a rag doll, simply falling forward.  She had to place her finger underneath her chin to support the weight of her head. Rotation, flexion and extension were all severely limited. 

Muscles  form our foundation.  The provide critical support.  This patient had an injury to her longus colli muscle.

The longus coli is located anteriorly and enables flexion and rotation of the spine.  It works in a complimentary fashion with the posterior neck muscles to stabilize the cervical spine.  Similar to the ropes that support a tent pole , if one of the ropes is cut the tent pole ( cervical spine) is no longer supported and typically falls to one side.

Understanding the importance of muscles and ligaments and their function is critical to understanding how injury occurs and what therapies are appropriate.  This is the standard at Centeno-Schult Clinic. For all those patients who have been in involved in a car accident and who have been told that it’s all their head there is hope.  It’s not in your head, its in your neck:)

First Practical Stem Cell Conference

The International Cellular Medicine Society (ICMS) will host it’s first annual conference in Las Vegas on 11/5/09.  What separates this conference from every other conference on stem cells is that this one will feature physicians who use cellular therapies everyday as part of their medical practices.  In the past, conferences have focused more on theoretical concerns.  Lectures will include: basic stem cell science by Henry Young, PhD-a scientist with 35 years of experience in culturing stem cells; the use of stem cells in Orthopedics by Christopher Centeno, M.D.;  the use of stem cells to treat degenerative disc disease by John Schultz, M.D.  and  regulatory issues for stem cell use as the practice of medicine by Christine Humphrey. Agenda can be reviewed here

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Diet: Its Impact on Stem Cell Growth

Despite their terrible taste, disgusting odor and foul texture I followed by mother’s instructions: EAT your brussel sprouts.

Mom insisted that diet was essential for our growth.

Does diet have an impact on stem cell growth and differentiation? (what type of cells they will become when they grow up)

Vanella demonstrated that high blood sugar levels, those commonly seen in patients who eat sugar based diets, lead mesenchymal stem cells to turn into fat instead of bone.

There are many factors that can affect stem cell growth and differentiation.  Regenerative Sciences understands the importance of these variables in their evaluation and treatment of orthopedic disorders with stem cell therapy. The Regenexx procedure provides patients a non-surgical option of the treatment of non-healing fractures, lumbar disc protrusions and degenerative conditions in knee and hips.

Bye, bye sugar and hello greens…..

Elbow Pain: Missing the Picture

Patient returned today after initial evaluation for lateral elbow pain.  She has a 5 year history of elbow pain, localized along the lateral aspect, constant in duration, progressive in nature without any radiations.  Pain was throbbing in character and aggravated by external rotation and her daily work responsibilities.  Therapies to date had included physical therapy, massage, chiropractic care, x-rays of elbow, evaluation by sports medicine physician, trial of anti-inflammatory medications and muscle relaxants. 

Physical examination demonstrated point tenderness along the lateral epicondyle and multiple trigger points in the extensor muscles.  Neurologic exam was normal.   Cervical spine had mild reduction in range of motion which was painful.  Specifically she had pain with extension and lateral rotation.

Given her poor response to conservative therapy, persistence of symptoms and neck pain and restriction motion, I was concerned that her pain was arising from a degenerate disc in her cervical spine.  That would make sense since the muscles in her arm which were painful receive their information from the C6 nerve.  If there is compression of the nerve root,  pain and muscle dysfunction can result.

Her cervical MRI demonstrated degeneration of the C5/6 disc and compression of the C6 nerve root.

A thorough examination is essential.  This is the standard at the Centeno-Schultz Clinic.  Regenerative options for this patient include prolotherapy, IMS, cervical injections with PRP and stem cell therapy.

PRP and Athletic Injuries

 Wanted to share the treatment of a local sports personality who responded well to PRP therapy.

Patient suffered an injury to the semimembranous which is one of the three muscles that comprise the hamstring.  He had significant pain in the back of this thigh which limited his ability to run.  he had point tenderness on examination with swelling and bruising.

 The semimembranosus muscle allows us to flex the knee, extend the hip and rotate our hip inwardly when the knee is flexed.

MRI demonstrated a tear in the muscle which is identified by the white arrow.

Patient underwent  a concentrated injection of his own platelets into the area of injury to stimulate repair.  This concentrate is referred to as platelet rich plasma (PRP).  Platelets are rich in growth factors which have been demonstrated to promote natural healing. After two injections the patient had 80% improvement and was able to return to playing.  PRP therapy affords patients a natural healing treatment with minimal downtime and the potential for significant results. 

PRP has been successfully used in professional athletes as witnessed by the treatments of Hines Ward  prior to the Superbowl.

PRP is just one of the regenerative therapies utilized at he Centeno-Schultz Clinic.