What is a rotator cuff tear?

A rotator cuff tear is an injury to the group of tendons/muscles that surround the shoulder joint called the rotator cuff where the tendon typically becomes torn away from the bone.  The rotator cuff is made up of the supraspinatus, infraspinatus, subscapularis and teres minor muscles and their tendinous attachment to the humerus (the arm bone). These muscles function to stabilize the shoulder and help control shoulder motion.

What are the signs of a rotator cuff tear?

A rotator cuff tear often results in a painful shoulder, particularly when trying to lift the shoulder overhead.  A larger tear can result in weakness or the inability to lift the arm overhead. The pain often is located in the shoulder and radiates down the arm partway toward the elbow.  Trouble sleeping on the affected shoulder is common.

What causes a rotator cuff tear?

A rotator cuff tear can be caused by an injury (traumatic) such as a shoulder dislocation or from a fall, or from gradual wear and tear (the most common).  Rotator cuff tears typically occur in adults and are less common in children. Repetitive overhead use of the arm over a long period of time is thought to be the most common cause of the wear and tear type of rotator cuff tear.  

What are the treatment options?

The treatment depends on the severity of the tear.  An MRI is often ordered to evaluate the problem and help determine the severity of the tear.  Most small/partial tears of the rotator cuff can successfully be treated without surgery. Often a regimen of rest, anti-inflammatories, therapy exercises, and/or corticosteroid injection can treat a small or partial rotator cuff tear.  A large tear where the tendon is pulled away from the bone would require surgery in order to repair this type of rotator cuff tear. The surgery is typically performed arthroscopically with small incisions in a minimally-invasive approach by the physicians at the Raleigh Hand to Shoulder Center.  An open surgical approach is another option for treating rotator cuff tears.

If you have signs or symptoms of a rotator cuff tear feel free to call our office to schedule an appointment with one of our fellowship trained Orthopedic hand and upper extremity surgeons that specialize in both the non-surgical and surgical treatments of shoulder pathology.

article by Dr George Edwards III

Video by American Academy of Orthopedic Surgeons

While our name may be new, it better reflects what we have been doing for years — caring for patients of all ages with hand, wrist, elbow and shoulder problems.

RHSC2019

One of the most common sources of elbow pain is tennis elbow. Tennis elbow, also called “lateral epicondylitis,” is a painful condition affecting many adult patients. Tennis elbow is caused by degeneration within the extensor carpi radialis brevis (ECRB) tendon on the outside of the elbow (lateral aspect). Despite the name, tennis elbow is not just limited to tennis players. In fact, tennis elbow is commonly diagnosed in patients between the ages of 30 and 50, and many patients have never played tennis.

Patients feel pain on the outside of the elbow and often point to a very tender spot near the lateral epicondyle bone (see image below). Symptoms can be aggravated by a forceful, repetitive activity with the hand and wrist, such as the tennis backhand swing or heavy gripping. Lifting light objects, gripping the steering wheel, and even simple household activities can be painful at times. Fortunately, the majority of patients with tennis elbow improve with non-operative treatment, although symptoms often take several weeks or months to resolve.

Golfer’s elbow, or “medial epicondylitis,” is a similar condition which causes pain on the medial, or inside, of the elbow. Both elbow pain conditions can be diagnosed in the office based on your symptoms, physical exam, and x-rays. MRI is typically not required to make the diagnosis.

What are the non-operative treatment options for tennis elbow?

• Braces:   Wearing a forearm strap or wrist splint

• Activity modification:   Resting, avoiding repetitive, heavy lifting or forceful gripping

• Medications:   Taking anti-inflammatory medications such as Motrin, Naproxen, or Tylenol

• Stretches:   Stretching the muscles of the hand, wrist, and elbow with exercises

• Hand Therapy:   A therapist can guide tennis elbow exercises and perform iontophoresis, ultrasound, or therapy modalities

• Corticosteroid injection:   Anti-inflammatory medication injection targeting the degenerative ECRB tissue can reduce pain

When is surgery recommended?

If non-operative treatment fails to improve the elbow pain after several months of conservative treatment, surgery may be recommended. During the outpatient surgery, a small portion of degenerative ECRB tissue is removed or “debrided.” This procedure is thought to stimulate healing of the normal surrounding tissues while removing the painful degenerative tissue. The type and length of incision varies among surgeons. This surgery is not a “quick fix” since returning to sports, heavy work, or weight training can take several months and additional therapy.

What are the results from surgery?

Most patients experience a significant reduction in pain, report improved function, and are satisfied with the outcome after tennis elbow surgery. However, not all patients experience complete pain relief and recovery can take several weeks to months.

Raleigh Hand Center doctors treat tennis elbow and other disorders of the hand and arm. Please call our office to be evaluated by an upper extremity specialist. 

Wrist injuries are very common. Treatment of wrist injuries is a specialized task because of the complexity of the area. There are 8 carpal bones including the radius and ulna bones of the forearm. There are multiple important ligaments which connect and stabilize the bones in the wrist and tendons which cross the wrist in order to move the fingers. Important nerves travel across the wrist to supply sensation to the thumb and fingers. Critical blood vessels supply nutrition and blood flow to the digits. 

Some wrist injuries are minor sprains and heal with a brace within a few weeks. Others are more severe and require casting, hand therapy, and sometimes surgery. Surgical cases include fixation of displaced wrist fractures, repair of ruptured carpal ligaments, repair of torn TFCC ligaments, decompression of the median nerve, repair of lacerated tendons, among others. Specialized evaluation is often important to make a proper diagnosis and involves a careful physical exam, history, radiographs, and possibly an MRI. For subspecialty evaluation in the greater Raleigh area please call our office for an appointment. Please watch this video from the American Society for Surgery of the Hand for additional information about broken wrists. 

Raleigh Hand to Shoulder Center Doctors are experts in the diagnosis and treatment of carpal tunnel syndrome. The also treat many other conditions of the hand and arm. Carpal tunnel syndrome is the most common nerve problem in the hand. It is caused from increased pressure on the median nerve at the wrist within the carpal tunnel. Symptoms such as hand numbness, tingling, weakness, and pain can result if the nerve is pinched. Patients often wake up at night with the hand numb and tingling. Carpal tunnel symptoms should be evaluated by a doctor, and not ignored.

The carpal tunnel is a passageway in the wrist through which the median nerve and tendons of the hand travel. This tunnel is a narrow and tight space. The bottom of the tunnel is made up by the carpal bones of the wrist and the roof is created by the transverse carpal ligament. The median nerve is at risk for compression within this tunnel. If there is abnormal swelling, altered wrist anatomy, or injury to this area, the function of the median nerve may be affected.

Patients with CTS commonly report “numbness” or “tingling” in the fingers. Some patients feel that the fingertips are “asleep” or report “poor circulation” in the hands. Symptoms often wake patients up at night. Some patients report increased symptoms while gripping a steering wheel. Dropping objects, clumsiness with the hands, or a weak grip are also common complaints. Some people also report pain in the forearm, wrist or fingers. In severe cases, the muscles at the base of the thumb (thenar muscles) can become weak and atrophy, sometimes permanently.

Often the diagnosis can be made on the basis of your symptoms, medical history, and physical examination. A nerve test can be ordered to confirm the diagnosis. Please call (919) 872-3171 to schedule a consultation with a hand specialist at Raleigh Hand to Shoulder Center in Raleigh, NC.

Surgical and non-surgical treatments are available.

Options include hand therapy, night splints, stretching exercises, cortisone injections, and carpal tunnel surgery.

Raleigh Hand to Shoulder Center doctors are members of the American Society for Surgery of the Hand. They treat conditions from the fingertips to the shoulder including carpal tunnel syndrome.

Dupuytren’s Contracture is a common condition affecting the hands. Patients with this condition develop nodules in the palms followed by fibrous cords extending into the fingers. In many patients, the cords gradually contract and cause the fingers to bend or flex. If left untreated, the fingers may remain permanently bent and impair hand function. Activities such as shaking hands, wearing gloves, and reaching into a pocket can be difficult. Fortunately, if treated in the early stages of contracture, the results are usually good to excellent and the results frequently last many years.

In mild forms of the disease, intervention is not always required. Once a finger contracts to the extent where the palm cannot be placed flat on a table top, it is usually time for treatment.

There is no cure for Dupuytren’s disease. The goal of treatment is to remove or break up the contracted palmar cords to allow for improved finger range of motion and better hand function. Recurrence of the contracture is possible with any of the available treatments. There are 3 main techniques used by hand doctors today:

Surgical excision (Dupuytren’s fasciectomy): this surgery is performed by the hand doctor in the operating room under the care of an anesthesiologist. During surgery the diseased, contracted Dupuytren’s tissue is removed through incisions in the palm. Patients are treated with splinting, wound care, and hand therapy for a few weeks during the recovery process. Results from surgery can last a lifetime and typically the results last many years.

Needle aponeurotomy (percutaneous fasciotomy): this less-invasive procedure is performed by the hand doctor in the office using the tip of a needle to perforate the Dupuytren’s cord using local anesthesia. Once the Dupuytren’s cords are weakened, the finger can be manipulated and straightened. Recurrence is common with this technique, but it is the least expensive option and has minimal downtime. The technique can be repeated for recurrent contractures in the future. Not all patients are good candidates for this procedure.

Collagenase enzyme (Xiaflex): this medication is used to treat Dupuytren’s contracture and was FDA approved in the United States in 2010. Xiaflex is an enzyme which dissolves the collagen fibers in Dupuytren’s cords. The Xiaflex injection is performed by the hand doctor in the office, and later that week the patient returns for a manipulation procedure under local anesthesia. The surgeon then manually pops the cord once it has been weakened by the Xiaflex medication. Patients are instructed in home exercises and splinting by therapy, and there is minimal downtime required after the procedure. Recurrence is common with this technique, but it can be repeated for recurrent contractures. Not all patients are good candidates for this procedure

As with any medical procedure, there are possible complications from these treatments. Complications from Dupuytren’s surgery include infection, poor wound healing, bleeding, swelling, hand stiffness, and nerve/artery injury. Complications from needle aponeurotomy include skin tears, nerve injury, and infection. Complications from Xiaflex include flexor tendon rupture, allergic reactions, hand swelling, bruising, lymph node swelling, and skin tears.

Dupuytren’s surgery, Xiaflex injection, and needle aponeurotomy are available at Raleigh Hand Center. Call 919-872-3171 to schedule a consultation with a hand doctor. 

Dr Erickson and Edwards III

Dr. George Edwards III and Dr. John Erickson returned from their Nicaraguan mission trip. The physicians traveled with the not-for-profit organization COAN (Cooperacion Ortopedica Americano Nicaraguense) to deliver orthopedic care to patients in Leon, Nicaragua. They also provided lectures to orthopedic residents and medical students in several teaching conferences and taught surgical techniques to residents in the operating room. The surgical cases included a wide variety of problems including chronic contractures of the fingers and wrist, nonunion of a radius fracture, chronic nerve laceration in the forearm, acute fractures of the hand, wrist and forearm, trigger fingers, and tumors of the hand and wrist. For more information about COAN, please visit their website here: https://www.coanhealth.org

Operating Room in Nicaragua

Nicaragua

Carpal tunnel syndrome is the most common nerve problem in the hand. It results from increased pressure on the median nerve at the wrist, within the carpal tunnel. Symptoms such as numbness, tingling, weakness, and hand pain can result if the nerve is compressed or “pinched.”

The word “carpus” means “wrist.” The carpal tunnel is a passageway in the wrist through which the median nerve and tendons of the hand travel. The carpal tunnel is a narrow space: the floor of the tunnel is made up by the carpal bones of the wrist, and the roof is created by the transverse carpal ligament. The median nerve is at risk for being pinched within this tunnel. If there is abnormal swelling, altered wrist anatomy, or injury to this area, the function of the median nerve may be affected.

WHAT CAUSES CARPAL TUNNEL SYNDROME (CTS)?

In most cases, the cause of CTS is unknown. Thyroid disorders, rheumatoid arthritis, pregnancy, vitamin deficiencies, diabetes, fluid retention, and trauma can be associated with CTS. Women are more commonly affected than men. Repetitive, forceful gripping and heavy use of vibratory tools may increase the risk of CTS.

HOW DO I KNOW IF I HAVE CARPAL TUNNEL SYNDROME?

Patients with CTS commonly feel numbness and tingling in the fingers. Some patients feel that the fingertips are asleep or report poor circulation in the hands. Symptoms are often worse at night and people tend to shake their hands for relief. Some patients report increased symptoms while gripping a steering wheel. Dropping objects, clumsiness with the hands, or a weak grip are also common complaints. Some people also report pain in the forearm, wrist or fingers. In severe cases, the muscles at the base of the thumb (thenar muscles) can become weak and atrophy. See image below.

Often the diagnosis can be made based on your symptoms and physical examination. A nerve study can be ordered to confirm the diagnosis in some cases.

WHAT ARE THE TREATMENT OPTIONS?

Not everyone with carpal tunnel syndrome needs surgery. Many people with CTS improve with non-operative treatment. Wearing a wrist brace at night supports the wrist in good alignment and takes pressure off the nerve. Corticosteroid injections provide an anti-inflammatory effect and can be effective in many patients. 

If nerve compression is severe, or if conservative treatment does not help, carpal tunnel surgery may be recommended. A carpal tunnel release (CTR) is performed to decrease pressure on the median nerve. During this procedure, the “roof” of the carpal tunnel (the transverse carpal ligament) is divided. Cutting the transverse carpal ligament increases the size of the carpal tunnel and provides more room for the median nerve.

The type of surgical incision varies among surgeons; however, the common goal is to reduce pressure on the median nerve. Open CTR and endoscopic CTR are two surgical options. The recommended procedure will be discussed with you with your doctor. Raleigh Hand Center physicians are experts in carpal tunnel syndrome treatment.