Subchondroplasty | An Alternative to Knee Replacement Surgery

Date and Time: 6 June 2019, 6.30pm
Venue: Peach Garden at Hotel Miramar
Guest Speaker: Dr Bernard Lee Chee Siang, Orthopaedic Surgeon at Sportsin Orthopaedic Clinic, Gleneagles Medical Centre

Dr Bernard Lee was invited as a Guest Speaker by Eplus Healthcare and Zimmer Biomet to give a talk about Subchondroplasty to a group of Orthopaedic Surgeons. He is one of three pioneer surgeons in Singapore who has been trained to perform this procedure.

Subchondroplasty | An Alternative to Knee Replacement Surgery

Below are some of the main takeaways from his talk:

What is Subchondroplasty?

Subchondroplasty | An Alternative to Knee Replacement Surgery

Subchondroplasty involves injecting a bone substitute into painful, damaged parts of an arthritic knee.

This surgical procedure can help patients with knee osteoarthritis. This has been shown to reduce knee pain and improve knee function significantly, without having to resort to joint replacement surgery.

70% of patients who underwent subchondroplasty avoided a total knee replacement for two years or more.

Radiologic Assessment before operation.

Your doctor may do X-rays and an MRI scan to assess the extent of your knee problem, and to determine if subchondroplasty is a good option for you.

Subchondroplasty has seen relatively good results in patients. It has helped some of them continue their lifestyle and work:  

Case-studies

1) A 67-year-old PE teacher was having severe knee pain and had difficulty climbing stairs and bringing his students for lessons.  Being an active person, he was not keen to undergo joint replacement surgery. After a few months of trying alternative forms of treatment, he underwent Subchondroplasty.  As the weeks passed, his pain improved, and he was able to continue working as a PE teacher. Currently, he is two years from his surgery, and his pain is almost completely gone.  He can still go for long walks every day and is still working as a PE teacher!

2) A lady in her early 50s was having knee pain due to knee arthritis that was aggravated by having to stand for long hours in her sales job.  After having tried other forms of treatment and supplements to no avail, she underwent Subchondroplasty. Now at two years after surgery, she only has occasional pain and can stand and walk for long durations at work without difficulty.

Subchondroplasty may not work for everyone.  However, it does provide an alternative to joint replacement surgery in certain patients.  Results will vary, and it is best that you discuss this option thoroughly with your Orthopaedic Surgeon.

For more information, please visit:

https://www.zimmerbiometcreativelab.com/zimmer/iframe_scp/index.html

http://subchondroplasty.com/patients.html

How to Prevent and Treat Osteoporosis?

Key Hole Surgery

Often when the topic of surgery comes up during the discussion with my patients, the question of how big will my scar be or how many stitches will there be comes up. The pleasant surprise will then commonly be that with current technology, many sports related joint injuries can be treated via small key holes now.

 

New Technology?

Truth is “Minimally Invasive (MIS)”, “Keyhole”, “Bandaid”, “Scope” surgery is not exactly that state of the art nowadays as it has been around for almost a century now and can safely be considered to be the mainstay treatment for most sports injuries.

 

Arthroscopic surgery has been reported since the 1910s but the technology and application greatly took off after the invention of fibre-optic cable when images can be projected into a television monitor. This saves us from having to struggle peering through a small peephole lens. This plus high definition lenses and monitors has made doing such procedures much clearer, easier and thus safer. Afterall, a surgeon should only operate on what he/she can see clearly.

 

So what exactly is KeyHole surgery.

KeyHole or Arthroscopic surgery is a type of orthopedic surgery that utilizes an instrument called an arthroscope which essentially is a lens connected via fibre-optic cable to a monitor. It is so called keyhole or minimally invasive as it can be performed requiring only small incisions, usually around around ¾ of a centimeter. These incisions are called portals. The word arthroscope is from the Greek words meaning “to look at joints.” The arthroscope is made up of a lens and a light source, and is connected to a video camera. The surgeon can view the inside of the joint directly through the arthroscope, or an image may be displayed on a monitor. This image gives the surgeon a clear view of the tissue inside the joint. The surgeon can then use other tiny instruments specially designed for arthroscopic surgery to perform necessary procedures. Arthroscopic surgery can be used as a diagnostic tool, or for therapeutic procedures ranging from easing the pain of arthritis patients to mending torn ligaments. This range from shoulder stabilization, rotator cuff repair, capsular release for frozen shoulder, acromioclavicular joint reconstruction (dislocation of the outermost part of the collar bone which many cyclist suffer from after a fall), tennis elbow release, knee meniscus debridement (clean up)/ repair, ligamentous (anterior and posterior cruciate) reconstruction, hip labral debridement repair. This is on top of the diagnostic arthroscopies we do for the joints and debridement of these joints.

 

Why KeyHole?

 

First I must quantify that although this technique is and can be used for many sports related injuries when all non operative options have been exhausted, it is not for every patient and every condition. In certain situations, trying to struggle through 4 to 5 small holes each around ¾ cm may cause more damage then just doing a simple mini-open procedure with a 3-4cm incision,

Nevertheless, extended exposure of joints during open surgery prolongs recovery and increases pain and risk of complications, such as infection and stiffness. Minimally invasive surgeries, in general, result in less pain and swelling after surgery than open techniques. As a result, arthroscopically treated patients tend to heal faster and begin rehabilitation earlier and, subsequently, return to normal activity and work sooner.

Technically, using a lens also allow surgeons to see certain parts of the joint that would otherwise be inaccessible through a limited mini-open incision as the lens can get into awkward corners of the joint easier.

Arthrocopic surgery has made some previously very long and arduous ones a lot more controlled and straightforward. This allow us to provide our patients a more predictable outcome in terms of results.

In some surgeries, arthroscopic techniques have become mainstays over open procedures like shoulder stabilization surgery, rotator cuff repair, acromioclavicular joint reconstructions, knee meniscus and ligamentous reconstruction. This is to an extend that the open surgery is only reserved for complex or revision (repeat) surgeries.

Another benefit of arthroscopy is that a lot of these procedures can be performed in an day surgery setting which can often reduce cost.

 

So what’s the down side?

As of all surgical procedures, there are risks. Like in all joint surgeries, risks include bleeding into the knee joint, damage to the cartilage, meniscus/labrum, or ligaments in the joint, blood clot in the leg (deep venous thrombosis), injury to a blood vessel or nerve, compartment syndrome when the fluid we use to pump into the joint to work (yes we work in an underwater environment) leaks into the calf area of the leg, infection in the joint and joint stiffness. Unique to arthroscopy, equipment failure accounted for a significant part of the complications. Arthroscopy is a technical procedure requiring a wide range of equipment (camera and monitor, surgical equipment, pump, tourniquet, etc.) that can malfunction or break during a procedure.

Conclusion

Arthroscopy, one of the greatest advances in orthopedic surgery in the 20th century, has been around for a almost a century. It offers a minimally invasive alternative to standard open surgical techniques, which often require extended incisions for adequate joint exposure to the extent that it has become the mainstay for many conditions. Decreased complications, pain, shorter recovery, and the resulting cost savings are proven advantages. Without a doubt, the advances of arthroscopic surgery will allow us to return our patients back to their peak performance a lot faster and with a lot less pain and fuss. With improvements in fibre-optics, lens and monitor technology, it will also allow surgeons to see clearer and as a result do better work for our patients, producing better results and allowing our patients not to have to live with their pain.

Common sports injuries faced by women

Disclaimer: This article first appeared in Shape Magazine as an Interview with Gleneagles

1. What are some of the most common sports injuries faced by women?

Women are increasing involved sports locally and the incidence of sports injury has increased as a result. Common injuries include those affecting the shoulders, elbows, wrists, back, hips, knees, foot and ankle. Different sports places increase stresses in different anatomical parts of the body and thus result in varying injuries. Sports injuries are broadly divided into 2 main groups

  • Traumatic injuries (sprains, muscle pulls, fractures, dislocations etc)
  • Overuse injuries (strains, tendonitis, tendinosis low back pain, etc)

Even in running, looking at the scientific literature, we can see that women indeed do, on the whole, get injured more often than men do.  But the difference is not quite as drastic as popular wisdom might hold—a 2002 study of around two thousand patients at a Vancouver, Canada sports injury clinic found that women represented 54% of injuries, with men taking up the other 46%.  But among some specific injuries, women are at significantly higher risk such as Anterior Cruciate Ligament (ACL) Tears.

2. What musculoskeletal and biological makeup differences between both genders contributes to sports performance and injuries?

There are many factors that attribute to the differences in injuries between the genders. The main reasons include

a. Anatomical Factors

Taking ACL injuries as an example: these factors include pelvis width, Q-angle (the angle between a line connecting a point on the front of the hip bone and the center of the kneecap and another connecting the kneecap and a point on the upper shin-bone), size of the ACL, and size of the intercondylar notch (where the ACL crosses the knee joint). Larger pelvis width, Q angle, smaller ACLs and a smaller intercondylar notch places females at a higher risk.

*  – Q angle is the angle formed by a line drawn from the ASIS to central patella and a second line drawn from central patella to tibial tubercle;
    – an increased Q angle is a risk factor for patellar subluxation;
    – normally Q angle is 14 deg for males and 17 deg for females;
           – Agliettis et. al. Clin. Ortho 1983:
           – 75 normal males:    Q angle = 14 deg (+/- 3)
           – 75 normal females: Q angle = 17 deg (+/- 3)
    – biomechanics of patellofemoral joint are effected by patellar tendon length & the Q angle;

b. Biomechanical/ Neuromuscular factors

Women have been found to have differences in biomechanic movements of the knee seen when pivoting, jumping, and landing — activities that often lead to an ACL injury. There is also a relatively greater imbalance between quadriceps and hamstring muscles (with the quads being stronger in females), which can contribute to knee injuries.

c. Training/ Conditioning factors (doll games vs ball games)

Until recent years, males are involved training actively for competitive sports at an early age compared to females. As such they are physically better conditioned to withstand sports injuries. Hence, boys being involved in ball games as compared to girls being involved in doll games at an earlier age. Nevertheless, the combination of the greater susceptibility and a 10-fold increase in the female sports population since the inception of Title IX in the United States has resulted in a dramatic increase in the number of ACL injuries in females. Locally, increased emphasis in sports and fitness has also allowed us to witness a large increased in the number of females involved in recreational and competitive sports and consequently an increase in the number of injured females.

d. Hormonal factors

Female sex hormones (i.e. oestrogen, progesterone and relaxin) fluctuate radically during the menstrual cycle and are reported to increase ligamentous laxity and decrease neuromuscular performance and, thus, are a possible cause of decreases in both passive and active knee stability in female athletes.

3. Are there certain sports that put women more at risk of injuries than men?

In view of the factors that lead to an increased risk of certain sports injuries, high demand sports involving planting and cutting, jumping with a poor landing, stopping suddenly or changing directions quickly (Soccer, Volleyball, Skiing, Lacrosse, Football, netball etc) can put women at a higher risk of knee sports injuries compared to men. Extrapolating this to other injuries including the shoulder/elbow/hip/ foot and ankle, women may also be at a higher risk of sustaining certain injuries compared to their male counterpart. For shoulder injuries, the combination of not having strong shoulder muscles, including the rotator cuff and periscapular muscles, and having generally supporting tissues that are more lax can lead to instability in the shoulder.

4. What are some sports that put women at an advantage compared to men? How so?

There are some sports where flexibility may play a greater role such as gymnastics where women are at an advantage. Interestingly, women are at a lower risk of hamstring injuries compared to men in a National Collegiate Athletic Association’s (NCAA) Injury Surveillance System (ISS) regarding all hamstring strain and rupture injuries in male and female soccer players between 2004 and 2009. Men were significantly more likely to suffer a hamstring injury during the in-season than women. Men are also more likely to suffer recurrent hamstring injuries.

5. As a member of the medical panel for the upcoming BNP Paribas WTA Final Singapore presented by SC Global, do you foresee any common sports injuries that the professional women tennis players will likely encounter? Perhaps our humid weather and brand new court grounds may play a role in altering their performance?

Tennis injuries are also of 2 broad types:

  • Traumatic injuries (sprains, muscle pulls, fractures, etc) make up about 1/3 of injuries seen in tennis, depending on the age and activity level of the player. Most traumatic injuries occur in the lower extremity. They are not easily prevented, nor are they particularly related to tennis technique.
  • Overuse injuries (strains, tendonitis, tendinosis low back pain, etc) comprise about 2/3 of injuries experienced by tennis players. Overuse injuries occur in all areas of the body, and may be related to technique or to alterations in the athlete’s musculoskeletal system.

Common injuries include tennis elbow, shoulder injuries such as rotator cuff tears, stress fractures, muscle strains, knee ligament strains/ tears, ankle sprains/ ligament tears and also back injuries.

Specific to ACL injuries, tennis players with an ACL deficient knee showed a clear incapacity to play on hard courts, where demanding eccentric deceleration motions occur. Frontal and rotational knee moments are thought to be increased when playing on hard surfaces owing to greater friction between the foot and the ground. Clay courts seem to be a better option for ACL deficient players.

6. What are some common injuries faced by recreational female tennis players?

Similarly, tennis injuries will include both traumatic and overuse ones. However, we do see a larger number of overuse injuries in recreational players. One of the reasons can be because of less consistent technique and form.

7. How can those tennis-related injuries be treated, and avoided?

There are multiple causes for the overuse injuries in tennis, including the need to perform repetitive forceful motions and strokes, inadequate rest and recovery, incorrect tennis specific conditioning, acquired inflexibility, and strength weakness/imbalance. Each injury may have unique causes that must be evaluated to avoid repeated injury, suggest proper conditioning programs, and allow safe return to sport. Because many parts of the tennis player’s body experience high loads on a repetitive basis, the musculoskeletal system must be prepared to withstand these loads. Much research has shown that an athlete cannot just play a sport to get in maximum shape for that sport, so a tennis player’s training plan should include a structured conditioning program that includes more than just playing tennis. Conditioning for tennis requires the exercises to be specific for the demands of tennis, and to be performed in a periodized manner in order to balance the workout load between conditioning and practice/play. As such, the roles of off the court strength training, conditioning, pre-game warming up and post-game stretching are very important.

When injuries occur, depending on the type and severity of injury, a consultation with your doctor will be advised. After a thorough medical examination and appropriate investigations, your doctor can then advise an appropriate management plan which will often include rest, cold compression, pain killers, anti-inflammatory medications, physiotherapy and rehabilitation. Surgery will be considered in cases where non operative management is not suitable.

8. How can a women’s menstrual cycle affect her sports performance? Is there a best and worst time for sports, according to the menstrual cycle?

There are some studies that show there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase. This is postulated to be due to oestrogen and relaxin’s direct effect on collagen metabolism and behaviour.

Oestrogen levels reach their peak during the follicular phase of the menstrual cycle just before ovulation and remain elevated until just before menstruation.

The effect of oestrogen on bone and ligaments include:

  • Inhibition of bone cells that breakdown bone (osteoclasts)
  • Inhibition of the development of new cells that breakdown bone
  • Promotes the survival of cells that build bone (osteoblasts)
  • Promotes the production of collagen in connective tissue including ligaments

Relaxin is produced during pregnancy; and in non-pregnant females during the luteal phase (2nd half) of the cycle. It peaks within 14 days of ovulation.

Effects of relaxin include:

  • Inhibition of collagen production
  • Promotes collagen breakdown

Taking into account the effect of these hormones, you might expect that women would be more vulnerable to injury pre-menstrually or at the beginning of the period when the ligaments would appear to be at their loosest. However, studies have shown inconclusive results. There are some studies that show there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase. However, some have shown a greater than expected percentage of injury mid cycle where you would expect the tissues to be at their stiffest and thickest.

ACL Tears in Tennis players

Tennis players did not admit to significant impairment when performing the majority of tennis strokes such as forehand, backhand, volleys, and serves. The major limitation referred to was landing after hitting a smash. This task has often been perceived by ACL deficient subjects as being difficult to carry out with confidence.8 Many players from the study group referred avoiding the smash entirely.

Interesting information was obtained about displacement while playing tennis. Injured players did not have significant impairment in forward running such as in “serve and volley” or “reaching a drop shot” movements. This finding was in agreement with previous studies—for example, Czierniecki et al found that running in a straight line may not generate sufficient rotational torque to initiate rotational instability in the cruciate deficient knee.9 In contrast, ACL deficient players show major limitation when trying to “stop suddenly and change direction”.

This type of stressful deceleration creates high anterior loading on the tibiofemoral joint.10 Both external varus‐valgus and internal‐external rotation place increased load on the knee joint during cutting movements compared with normal running.11 Varus‐valgus and internal‐external rotational movements are believed to be responsible for increasing knee joint ligament risk of injury. External flexion loads, valgus and internal rotation during sidestepping all have the potential to increase ACL and medial collateral ligament load substantially.11 The ability of normal subjects to undertake deceleration tasks without ACL rupture or giving way of the knee is attributed to the coordinated interactions among the ligamentous and other soft tissue passive restraints, joint geometry and congruency, friction between cartilage surfaces, active muscular control, and tibiofemoral joint compressive forces.10 Approximately 86% of shear forces are considered to be restrained by the ACL12; however, in ACL deficient knees these loads must be restrained by the articulating surfaces and the surrounding soft tissues.10

Most ACL injuries are indirect in nature yet occur during contact sports. Tennis involves tremendous forces during cutting, pivoting, and sudden deceleration manoeuvres; nevertheless ACL injuries are less common in tennis than in contact sports.13,14 In this series, most injuries occurred during contact sports such as soccer or rugby, but the exact mechanism (direct v indirect) was not determined. Sallay et al13 hypothesised that a tennis player is not as likely to sustain an ACL injury because of the ability of the neuromuscular system to coordinate muscular function in anticipation of each movement, with little surprise effect. Many investigators have indicated that anticipating a movement can change reflex responses and postural adjustments to minimise forthcoming perturbation and maintain appropriate posture.

Besier et al15,16 were able to confirm previous hypotheses indicating that knee joint moments increase under unanticipated conditions compared with preplanned manoeuvres, primarily because of a large increase in varus‐valgus and internal‐external rotational moments under unanticipated conditions. It is believed that unanticipated movement alters the external moments applied to the knee by reducing the time to implement appropriate postural adjustment strategies. Tennis may cause a low incidence of indirect ACL injury owing to the absence of frequent complete twisting manoeuvres and high jumping, as well as enough time for the player to anticipate strokes, especially from the baseline.

ACL injured players described significant impairment of their recreational tennis performance compared to preinjury level. Results from the present study may support the need for surgical treatment for competitive tennis players with ACL deficiency. Further studies are needed to determine the true incidence of ACL injuries in tennis, to analyse tennis motion knee biomechanics, and to establish the degree of improvement in tennis ability after ACL reconstruction.

Tennis players with an ACL deficient knee showed a clear incapacity to play on hard courts, where demanding eccentric deceleration motions occur. Frontal and rotational knee moments are thought to be increased when playing on hard surfaces owing to greater friction between the foot and the ground.11,17 Clay courts seem to be a better option for ACL deficient players.

Limitations of this study include problems associated with questionnaires, and shortcomings related to retrospective determination of the preinjury performance level.

In summary, complete rupture of the ACL is a debilitating injury that causes significant alteration of knee joint kinematics. Untreated patients have joint instability, chronic articular degeneration, and knee dysfunction. Tennis specific limitations related to complete isolated ACL rupture were clearly identified. Tennis players with an ACL deficient knee showed significant impairment of subjective sport performance, limitation in landing after smashing, limitation in stopping and changing direction, limitation when playing a three set singles match, and limitation in playing on a hard court surface compared with healthy controls.

Don’t Live with Shoulder Pain

Pain in the Arm 

“You know that feeling in your shoulder. It is a nagging ache and it goes down your deltoid. You cannot lie on your favorite side when you sleep and now you cannot rest well. You are starting to have problems with washing your hair and don’t even get started with putting on T-shirts and hanging up your clothes. This pain is affecting your swing/ stroke/bat. Come to think of it, it is getting to your other shoulder too.”

These are the common problems my patients with shoulder pain have to deal with on a daily basis. Three main issues bother such patients. Pain, Movement, Function which is a symptom translated from the pain and lack on motion.

The pain often radiates down the arm but stops short at the deltoid because the inflammation of the bursae (fluid filled sac) extends there. There is usually no numbness of the arm unlike a pinged neck nerve (cervical spine radiculopathy)

Functionally, the patient cannot raise the arm and thus is unable to wash his/her hair or face. The pain affect his/her sports performance. Often, the patient finds that he/she cannot follow through during the golf swing, have weaker strokes at the baseline or is having a weaker pitch.


Not everyone with Shoulder Pain is Frozen

The shoulder joint is a ball and socket joint. It is akin to golf ball on a golf tee (with the ball 3 times the size of tee) within a House.

Don't Live with Shoulder Pain

Looking at the diagram, there is a Roof (Supraspinatus tendon), a Front door (Subscapularis tendon) and a Back door (Infraspinatus and Teres Minor). Above the Roof, there is a Tree Branch (Acromion Spur). One of the reasons why there is a tear is because the Tree Branch keeps hitting the Roof and makes a Hole in the Roof (Cuff Tear). With a Hole, it leaks when it Rains and that can be quite a Pain!!

The Golf Tee (glenoid) is pretty flat and there is a CUP made of material that looks like Young Coconut Flesh (Labrum). This deepens the golf tee and makes the shoulder joint a more congruent one.

Don't Live with Shoulder Pain

There are three main common causes I see. These are:

  • Rotator cuff problems
  • Instability (labral problems)
  • Frozen shoulder

In my practice, Rotator Cuff problems outnumber instability 3:1 and Rotator Cuff problems outnumber frozen shoulder 4:1. Therein lies the necessity for a proper diagnosis. This is where a “completely new and innovative INVESTIGATION” technique becomes extremely important.

Let me introduce: a Proper History and Physical Examination

Even before we look into doing any scans, I believe that through a proper understanding of the patient’s problems and symptoms, finding out what exactly is affecting the patient, followed by a targeted physical examination looking for specific signs; a proper provisional diagnosis can be made. Using this knowledge, the Xrays and scans can then guide us like a satellite navigation map to decide what needs to be done for the patient. I believe that patients are the ones to be treated and not the scans.

 

Cuff problems

This is commonly also known as五十肩 (50 year old Shoulder), Urat bahu bengkak and commonly includes:

  • Impingement
  • Cuff Tendinosis
  • Cuff Tears which can be incomplete, complete or
  • Massive tear which can be Irreparable
  • Cuff tear Arthropathy (CTA)

Frozen shoulder

This is also known as Adhesive Capsulitis. As its name suggest, the shoulder is FROZEN. This means that the shoulder is stuck both actively (moves by its own power) and passively (moved by the other arm or someone else). It can be Primary (no one really knows why type) vs Secondary (caused by something else). Risk factors for Primary Frozen shoulder commonly include:

  • Endocrine causes (Diabetes Mellitus, Thyroid problems),
  • Neurological causes (Stroke)
  • Heart (Heart attack)
  • Secondary frozen shoulder can be due to shoulder fractures, Cuff issues or Labral issues too.
  • Labral Injuries

These often occur after an injury. Patients may have had a dislocation or a subluxation (partial dislocation) previously and the symptom of the shoulder being unstable is recurrent now. The labrum may tear at different areas and in additional to instability; patients may often complain of pain and may have painful clicks in the shoulder during certain movement. A proper examination will include looking for signs of instability, other types of labral tears and signs of generalized hyperlaxity (Loose jointed).


Don’t live with it!  

“See your doctor cos something can be done”

I cannot emphasize enough that a Proper History and Physical Examination leading to targeted Investigations will then bring about a Proper Diagnosis. This will include locating the source of pain, Range of Motion tests and Special tests. For labral injuries, we look out for Hyperlaxity Signs too. Thereafter, Xrays, Ultrasound and/or MRI/ CT scans are done and interpreted together with looking at the patient’s problems.

 

Get back your Swing

This will be based on the diagnosis and looking at what exactly is bothering the patient. (At Roland Shoulder & Orthopaedic Clinic, We Help Patients not Treat Scans)

Cuff problems

This depends on whether there is a hole in the roof or not and how big the hole is and if it is a complete hole.

If there is no hole, an incomplete hole or small hole, NON OPERATIVE management lasting for 3-6 months is often started. (There is nothing CONSERVATIVE about not operating)

This includes

  • Controlling Inflammation and pain – Analgesia (pain killers) and/or  NSAIDs (Non Steroidal Anti Inflammatory Drugs)
  • Subacromial (below the tree branch) Hydrocortisone & Lignocaine injections (I usually use 1% lignocaine with Triamcinolone)
  • Physiotherapy
    • Mobility Exercises
    • Strengthening of the
      • External and Internal Rotators

  Biceps

  Triceps

  Deltoid

  Scapular Stabilizers

For patients with Acute tears (occurring after an injury), Large Complete tears or patients that have failed non operative management, Surgery is offered. In my practice, a large majority of cuff problems which require surgery is done through Key Hole techniques now. This includes

  • Arthroscopic Subacromial Decompression and rotator cuff repair which is shaving down the offending tree branch above the roof and repairing the roof and/or repairing the front door too if that is torn.
  • Arthroscopic Mumford procedure (distal clavicle resection) if that is giving the patient problems .
  • Addressing the Biceps tendon (Tenotomy/Tenodesis) if that is giving patients problems .

Don't Live with Shoulder Pain

A large majority of shoulder problems are treated using key hole (Arthroscopic) techniques as they are can usually produce equal results to open surgery. Patients often have less pain, a shorter hospital stay and the scars are cosmetically more pleasing.

 

Don't Live with Shoulder Pain

However, this is not suitable for all cases and this depends of the condition and severity of the problem.

 

Frozen Shoulder

Primary Frozen shoulders follow a process of Freezing, Frozen and then Thawing. The thawing process can occasionally, unfortunately, last for a very long time of up to a year or 2. Seeing a doctor early will allow us to:

  • Ensure that the it is truly a Frozen shoulder. (again through a proper history/ physical examination/ appropriate scan/s)
  • Find out if it is cause by another shoulder problem (Secondary Frozen Shoulder)
  • Speed up the thawing process or if necessary, BREAK the ICE!

Speeding up the thawing process includes:

Non operative management of Glenohumeral H&L (injecting into the house itself), Physiotherapy, Medication like pain killers and anti-inflammatory medications. It is important to treat underlying issues if it is a secondary cause.

In my practice, if all else fails, I offer to break the ice but under direct vision. I kinda like to see what I intend to break. As such, I offer an Arthroscopic Capsular Release

 

Instability

For patients with labral injuries, if recurrent instability is the main problem, surgery should be considered early. This is because in younger patients, the risk of persistent instability is very high. With each dislocation, the risk of getting a large piece of the golf tee being broken off (Bony Bankart) or the golf ball being cored in (Hil sachs Lesion) becomes higher. As such, I offer Arthroscopic Shoulder Stabilization (Keyhole stabilization surgery) where the torn labrum can be repaired. This is for patients without a large piece of the golf tee that is broken off or a large part of the golf ball being cored. Unfortunately, if that happens, open procedures to restore the bone loss usually at the side of the golf tee may then be suitable.  

For some patients with a SLAP (Superior Labrum Anterior Posterior) tears (top part of the cup) or a posterior labral tear (back part of the cup), pain and clicking is the main problem. For patients with SLAP tear, I believe that a trial of non operative Management should first commence. This must include Scapular Stabilization exercises so as to provide a stable platform for the shoulder joint to mobilize. Only if that fails, I will then offer surgery to address the SLAP tear. In patients with posterior labral injuries complaining of pain and clicks, ASS can be offered to repair the cup.

 

What if the Whole House is Damaged?

For patients with Cuff Tear Arthropathy (damage to the shoulder cartilage due to prolonged roof tendon tear) and usually for patients > 65years, the option of a joint replacement is offered. This is because with the cartilage being worn out, a repair or replacement of the roof tendons will not resolve the arthritis causing the pain. In patients with CTA, a Reverse Shoulder Arthroplasty (RSA) is usually offered.

 

Don't Live with Shoulder Pain

This is a replacement surgery and it offers excellent pain relieve, a good functional Range of Motion of 140-150 degrees of forwards flexion. Patients can return to daily upper limb activities like comb/ wash hair, wash face, brush teeth after surgery.

 

In conclusion, you don’t have to live with your shoulder pain. Seek help early if the shoulder strain simply doesn’t go away after 2-3 weeks. A proper History and Physical Examination and Appropriate Investigations will usually lead to a Diagnosis and proper Treatment.

Q&A: Help! Experiencing shoulder pains when swimming

Question:

I’m just came back from my offseason and have started training again. I’m experiencing shoulder pains when I swim that I never had before. What are the possible reasons and what are the things I can do to keep it healthy for my new season?

Dr Roland Chong answers: 

Your pain sounds mechanical as it is exacerbated by swimming. There are several causes of mechanical shoulder pain ranging from those arising from the neck (cervical spine) to problems within the shoulder joint itself. The most common causes of persistent pain arising from the shoulder joint seen in triathletes include rotator cuff problems (impingement), acromioclavicular joint arthrosis(wear and tear), biceps (long head) tendonitis(inflammation)/ tendinosis(microtears) and labral (shoulder joint shock absorber) injury.

The location of the pain and association with other symptoms like loss of range of motion and clicking helps with differentiating the sources of pain. Pain on overhead activity, like those during the front crawl in swimming, suggests that impingement may be the most likely cause of your pain. Pain located at the acromioclavicular joint (protruding part at the end of the collar bone) or the long head of the biceps tendon (at the front of the shoulder joint) suggests problems there. Labral injuries often may result in sensations of instability, deep seated pain and also painful clicking.

I would recommend that if the pain is persistent and is hampering your training, a quick visit to your doctor should be considered. Also, ask yourself if the pain is affecting your daily activities like washing of hair, dressing or sleeping on your side. That suggests that the pain may be affecting your daily life in addition to your sporting lifestyle.

With a thorough history, proper physical examination and perhaps a targeted investigation, the root cause of your pain can be isolated and addressed accordingly. Often, improving the scapular (shoulder blade) stability and modification of your swimming stroke can help a lot in preventing the pain from recurring.

To reduce injuries to the shoulder joint, scapular stabilization exercises are important and can be easily done. I often recommend my patients to start by pulling their shoulder blades backwards, imagining they are trying to crack a nut between the blades. They are to hold that position for 10 seconds, doing it at least 5-6 times a day. Of course, if there is persistent pain that affects your daily life or sporting lifestyle, seeking help early at your doctor’s will help with getting back your second wind quickly.

Are Ironwomen more prone to Injury?

Women are very quickly becoming the fastest growing segment of endurance athletes. Studies suggest that women utilize less glycogen and more fat than men in long, lower-intensity exercise such as triathlons/ marathons/ pelotons. This makes female athletes particularly well suited for, and may potentially provide an advantage over men in endurance events. Triathletes are vulnerable to the full spectrum of sports injuries that could be sustained from swimming, cycling or running.

Although acute traumatic injuries can occur during an event or training, most triathletes suffer overuse or overtraining injuries.  Looking at the scientific literature in running, we can see that women indeed do, on the whole, get injured more often than men do.  But the difference is not quite as drastic as popular wisdom might hold—a 2002 study of around two thousand patients at a Vancouver, Canada sports injury clinic found that women represented 54% of injuries, with men taking up the other 46%.  Having said that, among some specific injuries, women are at significantly higher risk such as Anterior Cruciate Ligament (ACL) Tears.

Three main differences exist between the male and female athlete: Anatomical, Physiological and Training considerations.

Anatomical Factors

#1 Bones and joints.
Compared with men, women have shorter and smaller limbs relative to body length. In the athletic disciplines where balance control is very important (eg, gymnastics), shorter stature and wider pelvis give women lower center of gravity, which gives them substantial advantage. However, wider pelvis can produce a condition generally known as “knock-knees” which is a result of an increased Q angle. The Q-angle is the angle between a line connecting a point on the front of the hip bone and the center of the kneecap and another connecting the kneecap and a point on the upper shin-bone. This is known to be a predisposing factor for patellofemoral (knee cap joint) problems.

#2 Muscles
During the puberty, however, because of the influence of the testosterone boys accumulate greater muscle mass. In adults, total cross-sectional area of muscles in women is 60%, compared with 80% in men. As a result, maximal strength measures and maximal power measures are reduced. Although it has been shown that when only muscle quality is concerned, male and female muscle is not different. However, the strength and power differences between the sexes are a function of muscle quantity and not only of their quality.

#3 Ligaments and joints
Female athletes have increased general joint laxity than their male counterparts. It can be due to an increased laxity of the ligaments, tendons and the joint capsule itself. In addition, the lower muscle mass may also decrease the restrains of excessive joint movement in females.

Physiological factors

#1 Hormonal Differences

The predominant hormone affecting muscular and bone development in females is oestrogen and testosterone in males. After the stabilization of hormonal levels during the pubertal years, these hormonal differences results in greater gender differences. Proper oestrogen serum levels are also necessary for women to obtain maximum peak bone mass during the second and third decade. There are some studies that show there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase. This is postulated to be due to oestrogen and relaxin’s direct effect on collagen metabolism and behaviour.

Oestrogen levels reach their peak during the follicular phase of the menstrual cycle just before ovulation and remain elevated until just before menstruation.

The effect of oestrogen on bone and ligaments include:

  • Inhibition of bone cells that breakdown bone (osteoclasts)
  • Inhibition of the development of new cells that breakdown bone
  • Promotes the survival of cells that build bone (osteoblasts)
  • Promotes the production of collagen in connective tissue including ligaments

Relaxin is produced during pregnancy; and in non-pregnant females during the luteal phase (2nd half) of the cycle. It peaks within 14 days of ovulation.

Effects of relaxin include:

  • Inhibition of collagen production
  • Promotes collagen breakdown

Taking into account the effect of these hormones, you might expect that women would be more vulnerable to injury pre-menstrually or at the beginning of the period when the ligaments would appear to be at their loosest. However, studies have shown inconclusive results. There are some studies that show there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase. However, some have shown a greater than expected percentage of injury mid cycle where you would expect the tissues to be at their stiffest and thickest.

 

Training/ Conditioning factors (doll games vs ball games)

Until recent years, males are involved training actively for competitive sports at an early age compared to females. As such they are physically better conditioned to withstand sports injuries. Hence, there was a saying that boys were involved in ball games as compared to girls being involved in doll games at an earlier age. Nevertheless, the combination of the greater susceptibility and a 10-fold increase in the female sports population since the inception of Title IX in the United States has resulted in a dramatic increase in the number of sports injuries in females. Locally, increased emphasis in sports and fitness has also allowed us to witness a large increased in the number of females involved in recreational and competitive sports and consequently an increase in the number of injured females.

Common overuse injuries the ironwoman encounter include

Stress fractures

Stress fractures are relatively common overuse injuries, especially in athletes or military personnel. Although they are not exclusive to female athletes, females in general have a higher incidence of stress fractures and, second, distribution of stress fracture sites seems to differ between genders. Stress fractures result from cumulative repetitive forces insufficient to cause an acute fracture. It has been noted previously that stress fractures occur more frequently in amenorrheic (non-menstruating) than normally-menstruating females. The exact mechanism of the development of stress fractures in amenorrheic women is uncertain and may be partly related to low bone density. Lower-extremity bones are most commonly affected, but stress fractures also occur in non-weight-bearing bones such as upper extremities and ribs. The tibia (lower leg bone) is the most commonly involved site for both men and women, but the fractures of the neck of femur (thigh bone), foot bones, and pelvis are seen more commonly in the female athlete The athlete with stress fracture presents with gradual onset of pain, aggravated by exercise. The hallmark of stress fracture is localized tenderness at the fracture site. The main treatment of stress fractures is rest from the offending athletic activity, a concept known as “relative rest,” and it is usually conducted as a step by step treatment algorithm General conditioning is maintained by exercising other areas of body and partaking alternative training, such as water running, swimming, or cycling. When patients do not respond to conservative treatment, surgical procedure may be advised.

Patellofemoral (knee cap joint) pain syndrome

Patellofemoral pain syndrome (PFPS) is a term used to describe painful but stable patella. It is a very common problem among female runners and cyclists and the increased incidence of PFPS in women compared with male athletes is thought to be related to the anatomical, physiological, biomechanical and conditioning differences between genders. Three major factors contributing to the development of PFPS are lower extremity and patellofemoral malalignment, quadriceps muscle imbalance and/or weakness, and physical overload of patellofemoral joint.  Conservative treatment is effective in most patients. Quadriceps muscle stretches, balanced strengthening, proprioceptive training, hip external rotator strengthening, orthotic devices, and effective bracing will relieve the pain in most of the patients. Only if a comprehensive rehabilitation program of at least 6-month duration fails, surgical treatment should then be considered as the last resort.

Patellar (knee cap) tendinitis – jumper’s knee

Patellar tendinitis (jumper’s knee) is a clinical entity characterized with anterior knee pain and is the most common athletic injury to the knee. Pain is aggravated by excessive strain on the extensor (straightening) system of the knees after numerous jumps or long periods of running. It can also be caused by poor bike fit where the saddle height is too low, resulting a greater knee flexion. Important causative factor was found to be the amount of training (both the amount of time and the amount of mechanical strain placed on the knee) that the athlete habitually carries out. The most common site of tendinitis is around lowest part (inferior pole) of the patella. In very rare cases, continuation of intensive athletic activities, despite the presence of evident symptoms of the disease, leads to a complete rupture of the patellar tendon. Of the numerous treatments available, physiotherapy and correction of technical errors are often efficient.

Iliotibial band friction syndrome

The Ilitotibial band is a thick strip of connective tissue connecting several muscles in the outer thigh to help stabilize the knee. Iliotibial band friction syndrome (ITBFS) is one of the most common overuse injuries in runners. It is caused by many repetitive flexion and extension movements of the knee, during which rubbing of the band against lateral femoral epicondyle (outermost point of the thigh bone at the knee) occurs. Friction occurs near foot strike, predominantly in the foot contact phase, between the back edge of the iliotibial band and the underlying lateral femoral epicondyle. There is a higher incidence of ITBFS in long-distance runners than middle-distance runners and sprinters. The dominant symptom is pain at the lateral side of the knee, aggravated by running. Pain is stinging in nature, and is located around 2 cm above the knee joint line. The treatment is usually non-operative and is based on modification of athletic activity, stretching exercises, and correction of predisposing factors. Again, only in recalcitrant cases of ITBFS, surgery has been advocated.

 

Swimmer’s Shoulders

Swimmer’s shoulder is a musculoskeletal condition that results in symptoms in the area of the front and outer aspect of the shoulder. The onset of symptoms may be associated with impaired posture, shoulder joint mobility, muscular control, or muscle performance. Additionally, training errors such as overuse, misuse, or abuse may also contribute to this condition. In extreme cases, patients with swimmer’s shoulder may have soft tissue injuries of the rotator cuff, long head of the biceps, or glenoid labrum (shock absorber in the shoulder joint). For competitive swimmers and triathletes, it is important to focus on prevention and early treatment, addressing the impairments associated with this condition, and analyzing training methods and stroke mechanics. Often, a comprehensive rehabilitation program usually includes strengthening of the rotator cuff and scapular stabilizers, stretching anterior chest musculature that may be shortened, and implementing activity modification so the athlete can still participate in the sport. In cases where proper technique and rehabilitation are insufficient, a more thorough consult with the doctor may be required to assess for any significant injuries that may then warrant surgery as the last resort.

In conclusion, female endurance sports have come a long way and regular exercise is very important for obtaining general health, positive lifestyle behavior, and positive self-image, as well as learning such skills as teamwork, commitment, and goal setting. The collective differences in anatomical, physiological and conditioning factors may pose a higher health risk to the female athlete but the gender gap is definitely closing. If the symptoms of overuse injury surfaces and persists during training or competition, early diagnosis and a multidisciplinary approach are the essential aspects of the treatment. With a holistic, intergrated and personalized approach to peak performance, injury prevention and treatment, ironwomen can definitely swim bike run the world.

Weight Loss: The Golden Ticket to Osteoarthritis Prevention

My 8 year old daughter confronted me just a few weeks ago about the miracle creams and pills that the television advertisements are showing for arthritis. “There is no need for any more surgery then.” That led me to wonder: if these supplements and creams are the tickets to osteoarthritis prevention, that is really an excellent quick fix. No need to exercising either since running is terrible to our knees and ankles as the stomping trashes the joints. The marathoners must be destroying their knees! But are the professional runners really getting osteoarthritis early and more frequently then the rest of us?

In a study published when I was still doing 2.4km runs in less then 9.05mins, formerly competitive runners did not have higher rates of arthritis in their hips, knees or ankles when compared to nonrunners. (1)What about the regular recreational runners? A more recent study in the American Journal of Preventative Medicine investigated differences in the progression of knee OA in middle- to older-aged runners compared to healthy non-runners over two decades. No association was found. (2) Medical literature generally does not support the idea that running and exercising contributes to the degeneration of articular cartilage (3).

So what does? Whereas once knee osteoarthritis was considered a ‘wear-and-tear’ condition, it is now recognized that knee osteoarthritis exists in the highly metabolic and inflammatory environments of fat tissue. Chemicals known as cytokines associated with adipose tissue may influence osteoarthritis though direct joint degradation or control of local inflammatory processes. Moreover, obesity loads may be detected by mechanical receptors on cartilage cell surfaces triggering production of such chemicals leading to increased arthritis.

Fat (Adipose) tissue, once considered a passive storage of energy, is now recognized as a highly metabolic endocrine organ with the capacity to secrete such inflammatory chemicals which have been detected in the joint fluid and the blood of patients with osteoarthritis. (4,5) As doctors will tell you, inflammation is an important hallmark of osteoarthritis, and we give you anti-inflammatory medications to help reduce the pain and swelling from osteoarthritis. With the cytokines found in fat tissue being an important part of inflammatory processes, prevention can be done by reducing fat tissue where these nasty chemicals are produced. Voila, the golden ticket!

In addition to the nasty chemicals, being overweight also leads to abnormal loads on the joints. Clinical and animal studies of joint loading have provided evidence that abnormal loads can lead to changes in the composition, structure, and mechanical properties of articular cartilage. 6,7,8 Kind of like a watermelon placed on a grape, I guess you get the picture. But weight is not just the whole picture, loss of muscle mass and strength may reduce the shock-absorbing potential of the joint, thereby causing cartilage damage. 9

Pain is the main reason patients see me when they have osteoarthritis. Obesity has been known to be linked to abnormal glucose homeostasis (control) and insulin resistance in the body. In studies of acute pain in trauma and surgery, there is decreased insulin sensitivity.10 In these same studies of induced acute pain, there were increases in circulating concentrations of hormones associated with altered glucose homeostasis. Because obesity is frequently, though not always, associated with insulin resistance, altered glucose homeostasis has an important role related to chronic pain from the arthritis.

We have been searching for miracle drugs to reverse osteoarthritis for a long time to no avail. Of course, weight management, albeit the Golden Ticket to osteoarthritis prevention, may not be the quick fix everyone is looking for but I guess we can also defer to surgery like a knee replacement or an ankle fusion by Orthopaedic Surgeons like myself. We will always be available to help you with that when it comes to that.

Reference:

  1. Konradsen L, Hansen EM, Sondergaard L. Long distance running and osteoarthrosis. Am J Sports Med. Jul-Aug 1990;18(4):379-381.
  2. Chakravarty EF, Hubert HB, Lingala VB, Zatarain E, Fries JF. Long distance running and knee osteoarthritis. A prospective study. Am J Prev Med. Aug 2008;35(2):133-138.
  3. Willick SE, Hansen PA. Running and osteoarthritis. Clin Sports Med. Jul 2010;29(3):417-428.
  4. Dumond H, Presle N, Terlain B, et al. Evidence for a key role of leptin in osteoarthritis. Arthritis Rheum 2003; 48:3118–3129.
  5. Chen TH, Chen L, Hsieh MS, et al. Evidence for a protective role for adiponectin in osteoarthritis. Biochimica et Biophysica Acta 2006; 1762:711–718.
  6. Mundermann A, Dyrby CO, Andriacchi TP. Secondary gait changes in patients with medial compartment knee osteoarthritis: increased load at the ankle, knee, and hip during walking. Arthritis Rheum 2005; 52:2835–2844.
  7. Maly MR, Costigan PA, Olney SJ. Contribution of psychosocial and mechanical variables to physical performance measures in knee osteoarthritis. Phys Ther 2005; 85:1318–1328.
  8. Rejeski WJ, Craven T, Ettinger WH Jr, et al. Self-efficacy and pain in disability with osteoarthritis of the knee. J Gerontol B Psychol Sci Soc Sci 1996; 51:24–29.
  9. Bennell KL, Hunt MA, Wrigley TV, et al. Role of muscle in the genesis and management of knee osteoarthritis. Rheum Dis Clin N Am 2008; 34:731–754.
  10. Greisen J, Juhl CB, Grofte T, et al. Acute pain induces insulin resistance in humans. Anesthesiology 2001; 95:578–584.

Bone Loss – Perils of Treating Osteoporosis

Fragility fractures resulting from osteoporosis often require a long recovery period and can result in severe residual pain and immobility. Such fractures in the elderly often represent sentinel events and resulting in significant morbidity and even mortality. The prevention of such fractures involves fall prevention and the proper management of the underlying osteoporotic condition.

Osteoporosis is a systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue. World Health Organisation defines it as a bone mineral density (measured using a dual-energy X-ray absorptiometry scan) of 2.5 standard deviations or more below the young adult mean. Based on this definition, one-third of all adult females can be said to suffer from osteoporosis. One might even consider the onset of menopause as a harbinger for this condition.

The management of osteoporosis is based on 2 main principles: one seeks to attain maximum peak bone mass, even while reducing resorption. Most of our current first-line pharmacological treatments focus on the reduction of resorption. That said, bone is a living structure that has to heal and repair the accumulated damage it acquires. Anti-resorptive medication halts this process, leading to undesirable sequelae such as severe suppression of bone turnover (SSBT) and atypical fractures.

Careful patient selection, introduction of drug holidays, monitoring for signs of SSBT and management of atypical fractures have been undertaken by doctors dealing with osteoporosis with great interest over recent years, though many questions are still unanswered. Newer intramedullary nailing techniques have helped in the management of atypical fractures. In addition, the use of Vitamin D supplements has also played a great role in the management of the disease.

For peak mass and maximal resorption reduction, bone needs to be used and stressed – hence one would not be far off the mark to say: use it or lose it!