Frozen Shoulder

Few disorders in Orthopedics affect a patient as dramatically as frozen shoulder does. Most often the pain starts suddenly without any warning. And what puzzles the patient is that the pain starts without any fall or trauma. The pain is severe and is aggravated by any sudden movement of the shoulder. At times the pain is unbearable. The pain worsens at night and patients are unable to fall asleep. They cannot lie down sideways because of pain. The pain is accompanied by increasing stiffness of the shoulder. The patient becomes very anxious because of this catastrophic onset of pain and inability to move the shoulder. 

Frozen shoulder comes with good news and bad news. The good news is that the disorder is self limiting. This means that it is notan ongoing problem like arthritis which ends up with complete destruction of the joint. On the contrary frozen shoulder undergoes a typical evolution from stage to stage and then completely resolves. Therefore almost all patients of frozen shoulder will eventually be completely cured of their illness. Sofrozen shoulder is not a bad disease to have. What then is the bad news? The bad news is that it takes awfully long for the shoulder to get better. Typically a patient suffers for one year to 18 months before the pain goes away. 18 months is a long time for someone to suffer severe pain and sleepless nights!

What is frozen shoulder? In order to understand frozen shoulder we need to understand some simple facts about the shoulder joint. The shoulder is a ball and socket type of joint. Like all other joints the shoulder is strengthened by ligaments and moved by muscles. Similarly the shoulder also has a covering or lining called the capsule. The capsule makes and keeps the lubricating fluid within the joint. In frozen shoulder the capsule gets inflamed and contracted. This inflammation causes severe pain with the slightest movement of the shoulder. The contracture of the capsule causes the shoulder to become stiff. Frozen shoulder in medical terms is also called 'adhesive capsulitis'. We are still not sure why frozen shoulder occurs. However we do know some definite risk factors. It is more common in diabetic patients. It also is more likely to occur in patients who have not moved their shoulder for a long time due to some other reason like an arm fracture or stroke. Frozen shoulder is generally seen in adults above 40 and is slightly more common in women. There are three stages through which the disease progresses before it finally resolves. First is the stage of inflammation. It lasts for approximately 6 to 12 weeks. It is characterised by severe often unbearable pain. In this stage, pain is more prominent than stiffness. The second stage is of stiffness. In this stage the shoulder is very stiff with almost no movement occurring in some patients. The pain reduces in intensity in this stage. This stage lasts for another 12 weeks. The last stage is of thawing. In this stage the disorder resolves. Movements of the shoulder begin to improve and eventually the patient is cured. This stage lasts for 6 to 12 months. 

Are frozen shoulder patients destined to suffer? Is there any treatment for this disease or can these patients help themselves? There is no medicine to cure frozen shoulder. However the disability from frozen shoulder can definitely be reduced. The aim of treatment is to bring back the movements of the shoulder with range of motion exercise. A physiotherapist helps guide the patient through the exercise routine. Once the patients learn the exercises, they continue doing them at home. Those who try to regain movements by exercise are able to reduce pain and shorten the duration of illness. However exercise is many a times extremely difficult because it worsens the pain. Many patients are just not able to do any exercise. We as doctors help patients reduce pain so as to enable patients to do exercise.Initial pain management is with medicines. Tablets are given only with the intention to decrease pain so that patient can do exercise. Exercise remains the mainstay of treatment. If tablets do not work, local injection of steroid medicine is given to reduce the inflammation and pain. One or two injections of steroids do not harm the joint. Repeated injections should be avoided. Sometimes the patients are able to exercise, but are not able to overcome the severe stiffness. For such cases we do a manipulation under anesthesia. As the name suggests, the patient is given anesthesia so that they do not experience any pain. Then the surgeon forcibly moves the shoulder in all directions to loosen the joint. After the manipulation, the patient needs to continue exercise to gain the movements and benefit from manipulation. In very resistant cases, arthroscopic surgery is done to cut the adhesions and allow shoulder movements. 

To conclude, frozen shoulder patients should not be worried about the pain as the problem is self limiting and will get better in time. All attempts must be made to exercise and gain movements with the help of your doctor. Patients who exercise are able to shorten the period of their disability and achieve a cure quickly! 

Low Back Pain

Most people suffer from back pain at some point in their lives. Nowadays there is a lot of anxiety associated with back pain. The anxiety is because we constantly hear of patients undergoing an MRI for back pain and then surgery! Yes, there are surgeries that benefit certain conditions affecting the lower back and MRI is a wonderful tool that helps doctors do a detailed study of the back. But very few patients need an MRI and even less need surgery.

The spine is a complex structure of the human body. It starts from the brain and extends to the pelvis. It comprises of the neck, the upper back and the lower back. The back is made up of individual bones called vertebrae. Each vertebra is separated from the other by discs. The vertebrae conceal the spinal cord which is a downward extension of the brain. There are in addition a number of muscles in the back which make the vertebral column a mobile structure (so you can move your neck and bend your back).

In childhood the back is mobile, flexible and pain free. As a person grows older, the back ages as well. The discs degenerate and the joints wear out (arthritis and spondylitis). This is a natural process that happens to all people. Eventually in old age the back loses its flexibility and becomes stiff. Few lucky people undergo this natural process with little or no pain. Most of us however experience pain at some point during this course. This pain is the typical mechanical pain which most of us have had. It is the pain that is episodic (comes and goes). It is aggravated by exertion … sitting or standing for long periods of time. It is the pain that comes at the end of a long tiring day or during a bumpy ride. It is the pain that we get when we get up in the morning or get up after sitting for a long time. That is the commonest type of back pain and the type that we should not worry about! It does not need an X-ray and definitely not an MRI. We as doctors see this pain more nowadays because of poor lifestyle which includes unearthly working hours, poor postures while sitting, obesity and a lack of physical exercise. People who have this pain need to take rest till pain subsides, do back strengthening exercises and work on their postures while sitting, working and lifting weights. Unfortunately many such patients are unnecessarily over investigated with X-ray and MRI and some are even advised surgery! Patients need to be careful because surgery for this pain fails.

Another type of pain in the lower back occurs because of a problem elsewhere. Sometimes patients with a viral illness have fever, severe body ache and low back pain. This type of back pain is part of the illness and will disappear when the patient recovers from the viral fever. Many women get severe low back pain during pregnancy and after delivery. This is because of the strain of carrying the baby and hormonal changes. Such pain may continue for many months after delivery. But this pain is temporary and will subside on its own and one should not worry about it. Some women also get back pain during their periods. This pain is not related to the back and if it is very severe one should see a gynaecologist. At times a kidney stone causes back pain. This pain is intermittent, colicky and travels to the groin. It is usually very severe and your doctor will be able to diagnose it easily and guide you accordingly.

Which then are the types of back pain one should worry about? If the back pain is sudden and severe or unbearable, then obviously one needs to see a doctor. Most of such pains are due to a severe muscular sprain and these patients get better with rest and medication. Some of these patients have more serious problems like a slipped disc. In older patients the severe sudden pain may be due to a fracture of the fragile vertebral bone (osteoporosis).
One type of back pain that needs to be investigated is the one that doesn't get better. Especially if it interferes in the persons daily life, his/her job or recreation. And especially if routine treatments have failed.
Many times back pain is associated with shooting pain in the legs (sciatica). This is due to nerve irritation usually caused by a slipped disc.Again most patients with sciatica get better with non surgical methods of treatment and very few need an MRI and surgery.
Back pain after an accident needs to be assessed to rule out fracture or other injury.
The most serious types of back pain are due to infection or tumours. Luckily both these conditions are also the rarest.

To summarise low back pain is common. Many people suffer from it. The commonest type of low back pain is related to lifestyle issues like poor posture and lack of exercise. There is no reason to be overly anxious about low back pain. Don't be in a hurry to spend your hard earned money on an MRI!

WHEN NOTHING ELSE WORKS...

Most patients with advanced knee arthritis are still looking for that elusive cure. They are unable to accept that they need surgery. They strongly believe that something or someone somewhere can solve the problem with some magic medicine. They will keep trying fancy treatments like acupressure, rope therapy, braces, etc. The list goes on and on.

In all joints like the knee, the bone ends are covered by a smooth lining called cartilage. Cartilage ensures smooth, painless knee movements. Damage to the cartilage marks the beginning of arthritis. In advanced cases the cartilage lining is completely eroded. The bone below the cartilage gets exposed and bone starts rubbing on bone. This leads to severe pain. The real problem here is that cartilage does not regenerate or grow back. No matter what you try or which medicine you take, the original cartilage doesn’t come back. As the disease progresses and more and more cartilage is lost, the leg starts getting deformed at the knee. This makes matters worse. A crooked leg condemns the patient to more pain and disability. This pain can never go till the cartilage comes back and the leg becomes straight. Both these goals are impossible with non operative treatment!

So why does knee replacement work when everything else is failing? To understand this we need to understand the history of knee replacement. Researchers, scientists and doctors worldwide were struggling to solve the issue of arthritis since centuries. Initially they tried to replace the cartilage with other substances from the patient’s body like fat, fascia etc. But none of the structures they used had the qualities of cartilage and they would breakdown very fast and the procedure would fail. Then in the 60’s a genius called Sir John Charnley made a few landmark discoveries. He invented an extremely strong plastic called high molecular weight polyethylene. This plastic resembled cartilage very closely. The friction between this plastic and metal was as low as between two bones lined by natural cartilage. In addition to its fantastic friction properties, this plastic was also extremely strong. The other landmark discovery was of bone cement. This cement anchored the artificial joint to natural bone so strongly that the union lasted many years. These two discoveries changed the face of replacement surgery. Sir John Charnley designed an artificial hip joint which lasted 10 to 15 years. This was the first successful replacement. Using these landmark discoveries scientists started working on knee replacement. Finally after many attempts they achieved success and durable artificial knee joints were designed.   

Knee replacement works because it achieves both the desired goals. Cartilage is replaced by a strong and durable ‘cartilage like’ plastic. Furthermore the deformity is completely corrected after the surgery. As the damaged cartilage is replaced, the patient gets complete relief of pain. And as the leg becomes straight, this relief lasts many, many years. 

So does knee replacement work? Yes! It is one of the most successful surgeries of modern medicine. But it is a complicated surgery. To work it has to be done properly. The surgeon has to learn the technique and spend an adequate time in training. A well trained, experienced surgeon will do a good job almost every time. Infection is a constant threat to any surgery. In replacement surgery, infection can ruin everything. So in addition to a good surgeon, you need a good operation theatre.

These two factors are the reason, this surgery fails. An inadequately trained surgeon in a poor operation theatre is a recipe for disaster. Because of these issues, this wonderful surgery has earned a bad name.

 Instead of avoiding surgery because of fear which stems from a lack of awareness, I encourage patients to educate themselves regarding the pros and cons of this surgery and gain benefits.

What you KNEEd to know...

What is knee replacement?

Knee replacement is a surgery in which around 1cm of diseased bone and cartilage is removed and replaced by artificial metallic caps. The new joint surface restores normal joint movements and eliminates pain.

When is a patient ready for knee replacement?

1.       When pain is unbearable and constant

2.       When walking even short distances takes a lot of time and effort

3.       When the patient needs a walker or stick support to walk

4.       When the patient stops going out of the house for recreation, work or to attend social functions in fear of pain

5.       When deformity or limp becomes very severe

What are the advantages of this surgery?

1.       Complete relief of pain

2.       Complete correction of deformity

3.       Patient walks independently without help of a stick

4.       Patient can walk as much distance as he/she desires

5.       Patient can climb stairs

How long will a knee replacement last?

Knee replacement typically lasts for 15 to 20 years after which it may become loose and need a revision surgery.

How long will a patient have to be in bed after a knee replacement?

A patient usually walks within a couple of days after the surgery. The patient is able to go to the toilet on his/her own whilst in the hospital itself.

Is this surgery painful?

Most patients experience postoperative surgical pain. This pain can nowadays be well controlled with modern pain management techniques.

How long is the recovery?

Most patients need 1 – 2 months to recover completely and experience a pain free joint

What are the complications of this surgery?

Infection is the most feared complication. With modern theatre setup and discipline, infection rate is less than 0.6%. All other complications are rare.

Armed with this knowledge, the arthritic patient need not suffer anymore!