We Do Shoulders, Too!
By Thomas J. Blumenfeld, M.D.
Standing on the tee, the fairway stretching out in front of you, suddenly
you recall that twinge of pain you felt in your shoulder last week. You
thought it was gone, although, come to think of it, your shoulder did
ache last night. Taking two extra practice swings, you step to the tee,
and address the ball. At the height of your back swing a sudden pain shoots
down your arm. You wonder, “What did I do?”
Pain with overhead activity, night pain, pain with lifting objects, and
sometimes weakness, are all hallmarks of shoulder impingement syndrome.
The syndrome occurs due to both factors of how the shoulder joint functions,
and what occurs with aging.
As you know, normally you can put your arm over your head, out to your
side and over your head and in back of you. The same cannot be said of
the motion that you have in any other joint. The reason is that the shoulder
joint is a large ball and a very small socket (like a saucer). In comparison,
the hip is a ball captured in a deep socket (like a bowl). Because of
this arrangement the shoulder has a large range of motion. To stabilize
the shoulder, and allow you to move your arm, two muscles must function
together. The rotator cuff muscles pull the ball in to the socket and
keep it there, while the deltoid muscle, the muscle that gives the shoulder
its curved shape, lifts the arm.
In impingement syndrome, while the deltoid muscle lifts the arm, the rotator
cuff muscle does not work as well, and the ball lifts slightly in the
socket. Between the ball and top of the shoulder (called the acromion)
is a fluid filled sack or bursa, and the rotator cuff. Early in impingement
syndrome, the bursa gets inflamed (bursitis); if the condition persists,
the rotator cuff becomes weak (rotator cuff tendonitis), and can eventually
tear. With aging, due to chronic use of the shoulder, it is easier for
impingement syndrome to occur.
During an office visit the diagnosis is made based on the patient’s
history; a physical exam which may show some limitation of motion, pain
with passively lifting of the arm overhead or to the side of the body
(the impingement sign), and possibly some weakness; x-rays; and findings
that exclude other problems about the shoulder (referred pain from the
neck or a nerve problem, biceps tendonitis, or osteoarthritis).
Additionally a shoulder injection can be given, called a Neer diagnostic
injection, performed with xylocaine (and possibly cortisone) to aid in
making the diagnosis.
This syndrome, which is quite common, is treated with physical therapy,
anti-inflammatory medication, and shoulder injections of cortisone. Most
patients will receive relief from their shoulder pain, and less than 5%
of properly treated patients require surgery.
Surgery, called a subacromial decompression, involves creation of more
space for the rotator cuff so that impingement does not occur. This space
is created by removing the undersurface of the acromion. This can be done
via a small incision, or arthroscopically. At the same time that the undersurface
of the acromion is removed, the rotator cuff is inspected, and if torn,
can be repaired. In general, surgery is done either as an outpatient or
with an overnight stay in the hospital. After surgery more physical therapy
is required.
While Dr. Bargar and I specialize in replacement and reconstruction of
the hip and knee, I treat shoulders too! If you are having shoulder pain
either on or off the golf course, let me see you. Soon, you should be
able to return to your normal activities without pain.
The following words are used within a diagram:
Biceps
tendon
Subacromial
bursa
Acromion
Acromioclavicular
(AC) joint
Rotator cuff
Dear Doctor… Q. What is the healing process after the hip or knee surgery? A. The day after surgery a physical therapist will see you to start
your rehabilitation process. This starts with in bed exercises and sitting
over the edge of the bed and progresses to walking with a walker, on crutches
and then getting up or down a curb and stairs and in and out of a car.
Your body will start the healing process when the surgery ends. Patients
may experience numbness in the areas around the incision site. These normally
resolve as the small nerves near the skin grow back. Sometimes there are
permanent areas of no sensation. Once the staples have been removed and
the incision heals, gentle massage over the incision with some type of
lubricant (lotion, vitamin e oil, etc.) helps to loosen scar tissue.
The first three weeks following surgery will find most patients being
tired or tiring easily with postoperative exercises and ambulation with
crutches or walker. Gradually, your strength and endurance will return.
Q. What about taking anti-clotting herbs? A. Some of the herbs with possible clot protective benefits are:
garlic, gingko, ginger, and feverfew. If you are currently taking any
of these herbs, please inform your doctor. If you are anticipating any
surgery, you will be instructed to stop all anti-coagulant drugs or herbs
a few days before the procedure.
Q. What can I do to protect my rights under a managed care program? A. 1. Understand your health care. Ask for a document called “Evidence
of Coverage” or EOC.
2. Keep good records; date you called, who you talked to and the discussion.
3. Know your medical condition.
If you are not satisfied with your treatment there are some steps you
can take:
1. Consider getting help from family members or friends.
2. Talk to your physician.
3. Contact the medical group customer service or patient assistant.
4. Have the customer service representative explain the health plan’s
procedures and policies.
If you are still unsatisfied contact the California Department of Corporation
Health Plan Consumer Services at (800) 400-0815.
Local area numbers include: Health Rights Hotline (916) 551-2100; toll
free at (888) 354-4474, deaf and hearing impaired callers can use the
TDD line at (916) 551-2190. Any Medicare recipients or disabled consumers
can call the Health Insurance Counseling and Advocacy Program at (800)
626-2200.
Q. What does Board Certification in Orthopaedic Surgery Mean? A. The process includes the following components:
Educational:
• Must have graduated from an accredited medical school and passed
all exams necessary to receive an unrestricted medical license.
• Must have satisfactorily completed five years of graduate orthopaedic
surgery education in an accredited orthopaedic surgery residency program
in the U.S. or Canada. The residency training must include experience
with all age groups in operative and non-operative treatment.
Examinations:
After completing graduate orthopaedic surgery residency education a doctor
must meet the following criteria:
• Have a full and unrestricted license to practice medicine in the
US.
• Pass the Part I written exam relating to material taught during
residency training.
• Complete 22 months of practice of operative orthopaedic surgery
following
completing graduate education.
• Demonstrate professional proficiency and ethical practice based
on physician recommendations familiar with applicant’s practice.
• Pass the Part II oral exam based on a six-month list of operative
cases.
We are looking for a Few Volunteers
Patients that have had hip or knee total joint replacements or reconstruction
and who are willing to discuss their experience with those that are contemplating
surgery you may sign up for the volunteer list by either completing the
form below and mailing it to us or by calling our office, (preferably
on a Wednesday) and ask for Anna.
Please provide the following information:
Name
Phone Procedure (circle) Total Knee or Total Hip
Primary or Revision
Year of Surgery _____________________
Please be Patent, Patient
Effective October 1st of this year we started up on new billing and appointment
scheduling software. The most important reason for this change is compliance
with the Y2K (Year 2000) issue. This affects our patients in several different
ways.
We are transferring all the appointments and as you know, we call the
day before generally by 2:00 p.m., to confirm and verify that you will
be coming in to see the doctor. If you have not heard from us, you should
call us. A second item is that we are working all open accounts through
September 30th off the old system and new visits after October 1st will
be on a statement from the new system. It is possible that some of you
may receive two statements. The last item is when you do check in on your
scheduled appointment date, we will obtain copies of your insurance cards
so this date can be built in on the new system.
The staff is excited about the capabilities of the new software, but as
with all new things, there is a learning curve to overcome.
Spotlight on our New Employee:
Physician Assistant, Brian Shontz
My name is H. Brian Shontz, PA-C (Physician Assistant – Certified).
I joined Drs. Bargar and Blumenfeld in June 1998. Working with Dr. Bargar
in the office, I complete each patient’s initial history and physical
exam prior to their consultation with him. I also assist both doctors
in the operating room and with hospital rounds. I will be taking calls
for the doctors with one of them available at all times if needed.
My path to this position has been varied and interesting. After graduation
from UC Davis, though interested in physical therapy, I ended up in law
enforcement for 15 years. Then, just like many of you, I was diagnosed
with avascular necrosis (AVN) – a condition which leads to degenerative
joint disease. I underwent a total hip replacement in 1990 and retired
from law enforcement. While taking a year off to spend with my children
and explore the field of medicine, I discovered the potential career opportunity
of a lifetime, the physician assistant. I was accepted to the UC Davis
Physician Assistant program and graduated in 1994. Since graduation I
have worked in family practice and with work related injuries.
In my time away from work, I enjoy spending time with my family, gardening,
music and following UC Davis sports. My wife Selinda is a registered dietitian
who works for the American Heart Association and my children are Amy and
Hilary.
I am enjoying my new career very much and look forward to meeting each
of you.
We Do Shoulders, Too