|
ewardm
Mar 6, 2008, 8:18 PM
Post #1 of 21
(28648 views)
Shortcut
Registered: Mar 6, 2008
Posts: 3
|
I have a bone spur causing a problem with my supraspinatus tendon (to the ac joint). My orthopedist says the tendon looks unhealthy & suggests arthroscopy to shave down the spur -- 4 to 6 months recovery before starting to climb. I'm 64, lead 5.10 trad with the tendon in it's current shape and want to maximize my years left climbing at a reasonable level.
I'm trying to decide 1) do nothing until I can't climb reasonably or 2) get the surgery & hope I can recover to current level.
Any oldsters out there have experience doing this kind of recovery?
Thanks.
|
|
|
|
|
irregularpanda
Mar 6, 2008, 8:31 PM
Post #2 of 21
(28635 views)
Shortcut
Registered: Mar 13, 2007
Posts: 1364
|
ewardm wrote: I have a bone spur causing a problem with my supraspinatus tendon (to the ac joint). My orthopedist says the tendon looks unhealthy & suggests arthroscopy to shave down the spur -- 4 to 6 months recovery before starting to climb. I'm 64, lead 5.10 trad with the tendon in it's current shape and want to maximize my years left climbing at a reasonable level. I'm trying to decide 1) do nothing until I can't climb reasonably or 2) get the surgery & hope I can recover to current level. Any oldsters out there have experience doing this kind of recovery? Thanks.[/quote] I'm not an oldster, but I do have an undiagnosed shoulder injury (rotator cuff also). Being that I'm uninsured, you have it a bit easier than me, at least you have the option of surgery. I would give this advice, and its merely a reflection of what is going through my head: 1, climb your ass off this season, but safely. Do what you enjoy, go for mileage and super classic routes, but try not to do the ones that are overly shoulder-y (you know what I mean). 2. Everything recovers more quickly when its stronger. Get a physical trainer NOW, and use their advice for many months before going in for surgery. Its amazing to me that surgeons never tell people this simple fact! There are lots of rotator cuff exercise that will strengthen and stabilize the area, and it'll be better for you to recover in 4 months rather than 6, catch my drift?
|
|
|
|
|
onceahardman
Mar 6, 2008, 9:08 PM
Post #3 of 21
(28627 views)
Shortcut
Registered: Aug 3, 2007
Posts: 2493
|
Hi ewardm...
A little background...
Supraspinatus is one of the four rotator cuff (RC) muscles. The surgery you are describing sounds like a subacromial decompression. This is a painful and debilitating procedure. Nonetheless, it is sometimes necessary. 4-6 months before you START climbing??? more like start training to climb. It'll be a year to 5.10 again, if you are lucky.
Have you REALLY tried rehabilitating this injury conservatively? By that, I mean, good, aggressive, exercise-based PT? Many of my patients (and more than a few docs) have told me I'm not like the other PTs they've gone to. While this will not reduce the size of the spur, it can (and often does) improve the function of the shoulder enough so that surgery becomes unneccessary.
In fairness, if you ask a surgeon what's wrong, the answer is usually, "you need surgery". But if you ask a PT what's wrong, the answer is, "you need to exercise better"...when you are a hammer, you see the world as a nail.
Not much is lost by trying good PT pre-operatively. If you don't improve in 6-8 weeks, the surgeon can cut on it then, and you go in to surgery with better RC strength.
If you are markedly worse after 4 weeks of PT, you are probably a surgical candidate. But give it 4 solid weeks, and see what happens. Find a PT who works with athletes, rather than one who treats old ladies with broken hips at the nursing home. (No offense to those PTs-they do great work too.)]
If your PT has you getting a hot pack, ultrasound, e-stim, and cold pack, you are in the wrong place. You need an aggressive RC strengthening program. It may not work, but you will answer the question, objectively, as to whether surgery is necessary.
|
|
|
|
|
ewardm
Mar 6, 2008, 9:46 PM
Post #4 of 21
(28608 views)
Shortcut
Registered: Mar 6, 2008
Posts: 3
|
Thanks for the advice, but another question. The orthopedist says the spur will grow. If I keep climbing, will I trash the tendon, cause worse damage & have to permanently shut down after a while? Will I get warning in the form pain, less function, etc?
|
|
|
|
|
wonderwoman
Mar 6, 2008, 9:49 PM
Post #5 of 21
(28606 views)
Shortcut
Registered: Dec 14, 2002
Posts: 4275
|
I don't know about rotator cuff bone spurs, but at the ripe old age of 33 I seem to have one on my hand at the base of my thumb. I'm not going to get it removed because it may improve my crack climbing skills! 
I would second the need for seeing a sports doctor, though. I made the mistake of seeing an ortho for my rotator cuff who was used to elderly patients. He did not believe in physical therapy and instead put me on major anti-inflammation meds that gave me horrible stomach problems that I am still suffering from. Thanks, doc!
Good luck with the cuff!
|
|
|
|
|
scotchie
Mar 6, 2008, 9:50 PM
Post #6 of 21
(28605 views)
Shortcut
Registered: Jul 31, 2004
Posts: 261
|
Well I have a bone spur which caused bursitis (impingement syndrome), I have had this for ~ 1 year, and I have managed to avoid surgery for it so far....
What has worked for me is a cortisone injection combined with some stretching excersizes that I learned at the PT. The actual PT strengthening excersizes didn't really help me that much. The cortisone makes it feel better, and the stretching keeps it from coming back. But I haven't found a perfect solution.
I can tell you that the bone spur is going to make any type of PT treatment a lot less likely to work than it would for someone with the same injury but without the congenital defect. But that doesn't mean it isn't worth a try. It could work for you, and anyway if it fails, you can still go back and have the surgery later.
One point about shoulder problems to everyone out there. When I first started learning to climb, I remember reading or hearing somewhere to straight hang off that big jug to get a rest (hang without using the muscles). BAD TECHNIQUE! Always keep the arm a little bent and the shoulder muscles tensioned when hanging. It really doesn't sap your climbing energy since the weak link is always in the forearms, but it prevents all sorts of shoulder problems from occurring down the line. I wish someone had told me this when I started climbing!
|
|
|
|
|
onceahardman
Mar 6, 2008, 11:05 PM
Post #7 of 21
(28588 views)
Shortcut
Registered: Aug 3, 2007
Posts: 2493
|
Hi again.
First, let me respond to scotchie a bit. A bone spur is not a congenitaldefect. It is bone growth in response to trauma. The HUGE one in my right shoulder is the result of recurrent dislocations.
The spur will grow if the shoulder is subjected to the same mechanical trauma. By improving strength and function (and capsule stretching may well be appropriate for you, to improve function) you may well improve the function enough to decrease the repetitive trauma enough to stop (or slow down) the growth of the bone spur.
Long term, the course of untreated bone spurring in the shoulder is rotator cuff tear, and long head biceps tear. With treatment, these problems can often (but not always) be forestalled.
Will you get a "warning?" Maybe, but you may also just get a full-blown RC tear. Do you still have full range of motion?
One problem, and a question I'd like to get an honest answer to, from an orthopedic surgeon. When a surgeon "shaves down" a bone spur (and I have witnessed this procedure live in the ER), then what? What is the body's response to raw, cancellous bone? Well, the obvious answer is pretty severe inflammation. Inflammation is the body's chemical signal to send repair cells (fibroblasts), which build scar tissue. Now, the space formerly occupied by bone is instead occupied by scar tissue. Maybe this scar tissue can be remodeled, but maybe not.
I'll tell you this. I have never treated a subacromial decompression whose shoulder was ever 100% again. That's not to say you won't have a good outcome, but you'll never have the shoulder you had at 18 years old. So, I'd think twice, and do the conservative measures, and re-assess in two months. But work HARD for 1-2 months before deciding.
|
|
|
|
|
rockvoyager
Mar 8, 2008, 3:48 AM
Post #8 of 21
(28552 views)
Shortcut
Registered: Nov 11, 2002
Posts: 84
|
Man,what a timely thread.
I'm 58 years old and have been climbing for 20 years. My shoulder had been causing problems for several years after a run in with a gym move. While climbing in Thailand I felt a strange pain and decided to rest until the next day and see how it felt. Next morning I could barely move my arm. After returning home and getting an MRI I was diagnosed with a 1 inch tear in the RC and scheduled for surgery on 4/3.. The MRI showed a bone spur and the surgeon said it was this spur that caused the tear. The fix is to put in a couple of screws and suture the RC to these screws somehow. and take off the spur. He also said I would be in an arm sling for several months and it would be six months before I could do much of anything.
I guess I'm wondering if I should get a second opinion??
Brad
|
|
|
|
|
onceahardman
Mar 8, 2008, 4:57 AM
Post #9 of 21
(28540 views)
Shortcut
Registered: Aug 3, 2007
Posts: 2493
|
Yes. A second opinon is always a good idea. I've treated many RC repairs, and have never seen or heard of one tied off to a screw.
That doesn't necessarily mean it's not appropriate for your case, though. 1" is pretty massive. I wonder if the muscle has retracted a lot?
Make sure your surgeon treats athletes. Find someone who cuts on professional or major college sports teams. Good luck. Let me know if you have more questions.
|
|
|
|
|
rockvoyager
Mar 9, 2008, 1:32 AM
Post #10 of 21
(28522 views)
Shortcut
Registered: Nov 11, 2002
Posts: 84
|
Hardman
Thx for the reply.
The doctor comes highly recommended and enjoys a good reputation in the sports injury world.
I am reading the MRI results and it's all pretty much greek to me. It says; "this may represent a tear in the distal supraspinatus tendon. There is no retraction." This wasn't the surgeon but rather the on call doctor that did the initial read.
The surgeon said he could suture the tendon but I risked tearing the sutures. Apparently, suturing the tendon so it doesn't move until the healing process is completed will give me the best chance for recovery. At least that's what I think he said....
I'm a little uncomfortable with this. I think maybe a second opinion is smart.
Thx again for the info.
Brad
|
|
|
|
|
onceahardman
Mar 9, 2008, 1:42 AM
Post #11 of 21
(28518 views)
Shortcut
Registered: Aug 3, 2007
Posts: 2493
|
Hey Brad...
Is the surgeon then thinking of a second surgery for removal of hardware? It sounds that way.
I have a theory. If someone (say, a doctor) can't explain a complex problem in a way somone of average intelligence can understand it, he doesn't know the material well enough.
Ask questions! Write them down as you think of them. Write down his answers.
Best of luck.
|
|
|
|
|
wsclimber
Mar 12, 2008, 7:08 PM
Post #12 of 21
(28393 views)
Shortcut
Registered: May 24, 2004
Posts: 53
|
The anchors used eventually dissolve. IMO better to find a doc that has several decades of experience and is willing to go old-school and sew the tendon to the bone (for detachments anyways). problem with anchors, 1) they can pull out, 2) the knot from the thread used is under the cromimum and is thus a potential irritant every time you lift your arm.
good luck
|
|
|
|
|
onceahardman
Mar 12, 2008, 8:28 PM
Post #13 of 21
(28381 views)
Shortcut
Registered: Aug 3, 2007
Posts: 2493
|
In reply to: The anchors used eventually dissolve.
NO! titanium screws don't dissolve.
In reply to: the knot from the thread used is under the cromimum
Acromion?
Location of sutures is dependent upon location of RC tear.
|
|
|
|
|
timd
Mar 13, 2008, 5:19 AM
Post #14 of 21
(28362 views)
Shortcut
Registered: Dec 21, 2003
Posts: 862
|
I had the same problem and contrary to what these guys are saying you will not rehabilitate that shoulder while that spur is still there. That spur is causing the damage. I started out with cortisone shots and that did help because it lubricated the spur, however that spur was still causing damage to the rotator cuff. I had it surgically removed and was done with rehab in 3 months and climbing hard within 5 months. Just remember to do what the doc says and do your exercises regularly.
|
|
|
|
|
onceahardman
Mar 13, 2008, 5:09 PM
Post #15 of 21
(28328 views)
Shortcut
Registered: Aug 3, 2007
Posts: 2493
|
In reply to: you will not rehabilitate that shoulder while that spur is still there. That spur is causing the damage. I started out with cortisone shots and that did help because it lubricated the spur
Well, timd, I'm glad you had a positive overall experience with surgery. I'm also sorry you had a negative experience with more conservative rehabilitation.
Your experience is shared by many. So is a better outcome from conservative rehabilitation. Including my own experience.
I have dislocated my right shoulder in excess of 100 times, first in gymnastics, and doing all kinds of other things as it loosened further. (Only once while leading). After my long head biceps tendon tore, I had X-rays, which showed a huge (1 inch) osteophyte (=bone spur). I was in PT school at the time, and opted not to have the surgery. Aggressive rehabilitation strengthened my rotator cuff, allowing me to forego surgery. My shoulder has not dislocated in over 15 years. I had a grade 3 AC joint seperation 3 years ago, from a skiing crash, and the huge osteophyte is still there, even a bit bigger than before. I can still climb, ski, weight train, etc. Throwing is a problem, but fortunately, I don't make a living throwing 90 m.p.h. fastballs.
Edited to add: Oh yeah...The purpose of a cortisone shot is not to "lubricate" the spur. Steroid injections (cortisone) are very powerful anti-inflammatories.
(This post was edited by onceahardman on Mar 13, 2008, 5:15 PM)
|
|
|
|
|
volleymdut
Mar 13, 2008, 6:48 PM
Post #16 of 21
(28320 views)
Shortcut
Registered: Mar 13, 2008
Posts: 5
|
You want a surgeon? Here I am. I am an orthopaedic surgeon at the university of Iowa, and here is the low-down on the rotator cuff.
1. as you age, you tear the cuff, it gets worse. Starting at age 50, your chance of having a tear are ~50%, at 60 it's ~60%, and at 70 >70%. Now, just having a tear means nothing, as many are not symptomatic. Next, it will most likely get worse no matter what you do. Two recent studies showed that <10% of rotator cuff tears improve at all with no intervention.
2. Therapy is a great tool to manage symptoms. And if you ask me, that's all that matters. So what if you have a spur and a tear if you can do everything you want? A collection of studies would suggest that therapy alone is sufficient to get you back to activity 60-85% of the time.
3. The purpose of surgery is also to alleviate symptoms ONLY. The true purpose of a repair is NOT necessarily to make you stronger or more functional. It may maintain your current level of function, make you feel great, but you won't suddenly be climbing things you never climbed before. (I know that's not what you're looking for, I just wanted to throw that out there)
4. Recovery is long. I tell my patients it will take one full year to return to normal sporting activities (these are usually division 1 overhead throwing athletes).
5. The question about imflammation and scar tissue remodeling is interesting but clinically irrelevant. The results with subacromial decompression (shaving the bone spur on the underside of the acromion) also involves removal of an already wildly inflamed bursa (a sack of tissue between the rotator cuff and acromion) which is a HUGE source of pain. Subacromial decompression alone is a HIGHLY successful way to eliminate shoulder pain, even in a shoulder with a rotator cuff tear that is NOT repaired. Do a google search on these studies and you will find several.
6. Fixing the rotator cuff. At my institution there are some surgeons who do this through an "open" approach and those who do it through a scope. Open means they use an incision big enough to see the tear and repair it with the naked eye. The literature over the last 5 years has shown the two techniques to now be roughly equivalent in functional outcome, but the recovery from a scope procedure is much faster. There are also variations in the type of fixation. In general they are all the same. I think you and onceahardman are a little confused on this point. The rotator cuff tendon will not heal if sutured to itself. it must be anchored to bone in some way. Most fixation consists of a screw (titanium, or bioabsorbable, it doesn't matter much) anchored into the bone with an eyelette on the superficial end of the screw through which sutures pass. The sutures then pass through the tendon and pull it down to the screw. Healing then takes place at the tendon/bone interface. There are many variations on this theme, but it is not necessary to talk about them at this point. The screws are NEVER intended to come out unless an infection occurs, or if they come out of the bone and are floating around in the joint. Both of these complications are EXTREMELY rare.
My advice, without having examined you and the MRI myself: maximize your non-surgical options. Exhaust them. Then, if you decide surgery, do it at a point in the year where the recovery period will sacrifice the least climbing!
Any other questions feel free to let me know.
|
|
|
|
|
onceahardman
Mar 13, 2008, 7:42 PM
Post #17 of 21
(28306 views)
Shortcut
Registered: Aug 3, 2007
Posts: 2493
|
Thank you, doc. Your info and corrections are greatly appreciated. The "screw" procedure was offered to me when I saw my MD following my long head biceps tear. I was not aware the same procedure was used for RCs.
If the tear is in the muscle belly, rather than the tendon, is a screw still needed?
Regarding your #1, and the damage to the RC which correlates with age...I have been told this also correlates with decreased vascularity of the RC with age, which can (theoretically) be forestalled with consistent RC strengthening.
Thanks also for the info on subacromial decom. All I can say is, clinically, my patients are in REALLY severe pain afterward, and outcome seems related somewhat to *personality*, as unscientific as that is. Frankly, a significant percentage gives up, and don't do their home program, and quit PT. But, you are right, regarding clinical relevance.
Again, thanks. Don't be a stranger.
ps, MY 1+"osteophyte is at the inferior/anterior aspect of the glenoid, not in the subacromial space.
EDITED:
One more question. When my biceps repair was suggested, I was told the torn biceps tendon would be stitched down in the bicipital groove. The purpose was to maintain the length/tension relationship of biceps. Since the long head would no longer cross the shoulder joint (and thus improve stability of the GH joint), I opted to not have the procedure. No regrets. Anyway, when the (say) supraspinatus tendon is stitched down, clearly it MUST be stitched into the humerus. What if the tear is at the musculotendinous junction? Intuitively, it seems a long way to "stretch" the intact portion to screw it into the humerus. What does this do to the length/tension relationship?
If both ends are stitched into the subacromial space, how does supraspinatus generate any tension on the humerus?
Thanks.
(This post was edited by onceahardman on Mar 13, 2008, 7:57 PM)
|
|
|
|
|
dynosore
Mar 13, 2008, 8:18 PM
Post #18 of 21
(28300 views)
Shortcut
Registered: Jul 29, 2004
Posts: 1768
|
I've had this done to both shoulders. Most recently, my right arm on Dec. 19th last year. Trust me, it isn't going to get any better on its own. Therapy did nothing, actually seemed to aggravate it, and I tried different therapists. I even quit climbing for 6 months, but it still kept getting worse. Once that rubbing irritation starts, it seems to build on itself.
I recovered and was climbing within 3 months. I'm 33, so I'm not an oldster, but I sure don't heal like I did when I was 18 either.....
(This post was edited by dynosore on Mar 13, 2008, 8:20 PM)
|
|
|
|
|
rhei
Mar 15, 2008, 12:26 AM
Post #19 of 21
(28257 views)
Shortcut
Registered: May 13, 2003
Posts: 71
|
The OP asked for anecdotal views from oldsters, so here's one experience that can added to the decision-making process.
When I began experiencing pain in my left shoulder, I visited an orthopaedic surgeon and had an MRI of the area done. I was diagnosed with a small bone spur and a minor tear in my left rotator cuff. After discussing options with the surgeon, I decided against surgery and initiated PT exercises specific to the problem and stuck with them religiously. I continued to climb at the level I had been prior to seeking help. Initially, PT seemed to lessen my pain, but after about 16 months there was a dramatic increase in my discomfort and a concurrent loss of mobility and strength. Presumably I'd expanded the tear. I threw in the towel and opted for surgery. I was 56 at the time.
I scheduled surgery for November, at the end of my usual climbing season. I continued the strengthening exercises right up to the time that I went into the hospital. Surgery involved two scope entry points and an incision through the deltoid roughly 2 inches long. A few weeks after surgery, I began working with a therapist on restoring range of motion and then, after some 8 weeks, gradually regaining strength. Again, I followed the PT regime scrupulously.
I began climbing again after 16 weeks, typically one day per weekend, but with a couple of trips involving consecutive climbing days thrown in. By July I felt fit enough for a two week trip to the Valley. At that point, any problems I had were the result of my modest technique and strength, not my shoulder. In the two years since, I've had no recurring problems and I'd estimate my range of motion recovery at 100%.
As has already been stated, be conservative in opting for surgery. If and when you do, and if my experience is any indicator, pre-surgery preparation will hasten recovery (a point also made by onceahardman). Best wishes for a good outcome, whatever your choice.
PS. When I came to in the recovery ward, I discovered the surgeon had hooked up a little tube directly into the incision site that ran down to a small vial of pain killer that periodically was pumped into the wound. He said this was a common post-operative technique with C sections and he had great success using it for pain suppression in shoulder surgeries. Fine with me. I heard the first post-op week was pretty painful with RC surgery, so the idea sounded good. The pump lasted about 24 hours, and there was never enough drug in me to make me sick (a problem I have had with other pain killers). I had very little swelling and very little pain after that. Nice treatment. If you go in for surgery, ask about it.
|
|
|
|
|
toller
Mar 31, 2008, 4:04 AM
Post #20 of 21
(27857 views)
Shortcut
Registered: Feb 6, 2003
Posts: 11
|
I didn't read all the other replies, but thought my experience would be useful.
My orthropedist told me I should try therapy, but it would be useless. After a month I wasn't any better and the orthro said I should have surgery. The therapist said the surgery was much worse than the othro let on and I should continue therapy until I was better. I did another month of therapy and was fine. That was three years ago, and I am still fine.
Presumably it will catch up to me someday, but they will better procedures by then.
Good luck.
|
|
|
|
|
ewardm
Mar 31, 2008, 12:55 PM
Post #21 of 21
(27848 views)
Shortcut
Registered: Mar 6, 2008
Posts: 3
|
Thanks for all the posts. I found them very helpful. In the end I went to another orthopedist who flatly contradicted the first doctor. He said the problem was arthritis in the joint -- cartilage that was degenerating and cartilage completely missing, and the joint space is a third of what it should be. The bone spur, he said, is inconsequential. His advice: continue to be active which is helpful for arthritis. I believe him and am off to the rocks.
|
|
|
|
|
|
