What do you do if you have continued pain after ROTATOR CUFF SURGERY
Continued shoulder pain even after a surgery for tears does happen. When complaints persist and have become an unresolved shoulder pain, I am called upon to help patients make decisions what to do next. Helping patients learn about the available treatment options and understand their choices is a discussion that needs to take place. When I discuss Rotator cuff surgery I refer to Lädermann A, et al. from the University Hospitals of Geneva. They state that “Tear recurrence can be related to various factors such as:
(1) Inadequate strength of the initial repair construct
(2) Biological failure to heal despite strong initial fixation (hardware and suture) and
(3) inappropriate postoperative rehabilitation causing structural failure of the repair” (1).
We always hope for good outcomes after a surgery but “The results of (rotator cuff) treatment are not as predictable as the patient (family, trainer, coach and doctor) would like to think” says Nickolas G et al. in the Physical Medicine and Rehabilitation Clinics of North America journal.
I talk to patients about the concept of cellular communication and how there could be a breakdown in the local tissue area and even the brain to stimulate proper healing. We have learned that certain therapies such as stem cell injections, shockwave, and laser can seem to jump start a non-healing area within a damaged shoulder or knee joint. The current thinking is that these therapies change the joint environment from non-healing (diseased) to healing by signaling the local native resident healing cells to get ready to rebuild.
How, can I as a Chiropractor change the joint environment from not healing to healing and working better?
- By inducing gentle non-painful motion into a poorly functioning joint.
- By re-awakening stem cells to change (plasticity) and activate (multipotency – the ability to change/morph into other cell types and multiply). I use shockwave to do this.
- Get the surrounding healthy cells to send signals to suppress inflammatory T–cell proliferation (inflammation) and provide an anti-inflammatory effect. I use laser to do this.
Maybe the above 3 points help activate stem cells to express various growth factors – it takes a lot of reawakening of molecules to stimulate local tissue repair. I like the concept of getting cells to communicate directly cell to cell (even to the resident remaining cartilage cells) in the joint. Seol et al did a study to show that stem cell activation regenerated cartilage in knees, why not the shoulders! (3)
- Lädermann A, Denard PJ, Burkhart SS. Management of failed rotator cuff repair: a systematic review. Journal of Isakos. 2016;1(1):32-37. doi:10.1136/jisakos-2015-000027.
- Nickolas G. Garbis, Edward G. McFarland. Understanding and Evaluating Shoulder Pain in the Throwing Athlete. Physical Medicine and Rehabilitation Clinics of North America, 2014; 25 (4): 735 DOI:10.1016/j.pmr.2014.06.009
- Seol D, Zhou C, et al. Characteristics of meniscus progenitor cells migrated from injured meniscus. J Orthop Res. 2016 Nov 3. doi: 10.1002/jor.23472.
Serious athletes come in to my office with complaints of back pain and/or hip pain. Their medical doctors have recommended steroids and/or cortisone injections, but these patients want to try something else before risky shots or pills. These patients are savvy, they think long term recovery. They want what the pro-athletes get! They usually already had the MRI, and they have tried to work it through on their own. They want my advice because they heard I take the time to help them figure out the cause of the pain. The question I need to figure out “Is your movement pattern irritating a disc problem, ligaments, or the muscle system?” Then we figure out the best treatment plan together.
Patients are hearing about Platelet-Rich Plasma Therapy (PRP), stem-cell regeneration therapy, shockwave therapy, laser, Deep Muscle Stimulator, and other “locker room” treatments for the pro’s. I organized my office so the average person can get what the pro’s get. I use 3 types of shockwave or pulse therapy, and 2 types of laser that create effective treatments for disc injuries, muscle pain, and spinal ligament instability.
Shockwave therapy, laser therapy and the proper movement therapy stimulates the regeneration of the discs. ligaments and muscles directly. Yes, decreased disc height can be changed and scar tissue can be broken up. As with any treatment, the earlier and sooner the treatment intervention begins the better the outcome.
I constantly look for research that helps recovery in sports injuries and therapies that offer effective therapeutic results.
If you want to try therapies that the top pro athletes are getting to alleviate back pain and hip pain call my office at 310-444-9393.
If you are suffering from a known knee meniscus tear get out your MRI report…
If you have a meniscus tear the radiologist probably used phases or words like located in the “White Zone” and/or “Red Zone” meniscus tears. The “Red Zone” refers to the outer edges of the meniscus and has a fair amount of blood vessel in it. Areas that have a good blood supply typically heal better than those areas without good blood flow. If the radiologist describes your tear as being in the “White Zone” that refers to the center of the meniscus which has a poor network of blood flow. White zone tears are often recommended to have surgery.
The red zone (good blood flow) is known to contain regenerative cells, (cells that stimulate stem cell activity) and those of us using Shockwave Therapies (Zimmer EnPuls, EPAT, Acoustic Wave Therapy, Gaines Wave), hypothesize that shockwave treatments to the knee can help stimulate migration of the regenerative cells in the red zone to the site of meniscal injury in the white zone. Shock wave practitioners know the meniscus is capable of healing tear defects that occur in the white zone (the area without circulation).
Shockwave Therapies (Zimmer EnPuls, EPAT, Storz, Acoustic Wave Therapy, Miracle Wave, Gaines Wave) is a non-invasive alternative to shots and surgical treatment. Shockwave therapy may act as a spark to mobilize the body’s own stem cells to facilitate healing.
Findings in the Journal of Orthopaedic Research demonstrate that articular cartilage and injuries to the meniscus mobilize an intrinsic progenitor cell population with strong reparative potential, even into the white zone area (2).
1 Matar HE, Dala-Ali B, Atkinson HD. Meniscal regeneration: a cause of persisting pain following total knee arthroplasty. Case reports in medicine. 2011;2011.
2 Seol D, Zhou C, Brouillette MJ, Song I, Yu Y, Choe HH, Lehman AD, Jang KW, Fredericks DC, Laughlin BJ, Martin JA. Characteristics of meniscus progenitor cells migrated from injured meniscus. Journal of Orthopaedic Research. 2016 Nov 1.
Many patients come in to see me for knee pain. These are patients looking for non-surgical options for meniscus injuries, patellofemoral syndrome pain, knee osteoarthritis and ligament injuries. Most people are familiar with arthroscopic surgical procedures and they are hearing about stem cell therapy for joints. But most people have not yet heard about extracorporal pulse attenuating therapy (EPAT), acoustic pulse therapy, radial pulse therapy or shockwave therapy. These are alternative non-invasive regenerative therapies for knee damage.
Most doctors still believe that the inner knee meniscus cannot heal because it has a poor network of blood vessels and blood supply. But newer research is discovering the meniscus is always trying to heal itself.
How does acoustic shockwave therapy help a meniscus regenerate?
1. Re-establish the normal outer soft-tissue textures. If you are swollen shockwave helps get it resolved.
2. It can aid in bone and joint alignment (ankle, femoral, tibial and hips). This may require a skilled Chiropractor.
3. Restore normal range of motion.
4. Shockwave therapies such as the Zimmer EnPuls, PiezoWave Acoustic therapy and the Storz EPAT are used to stimulate the growth of new meniscus tissue and help your own stem cells to do the job of repair. A shockwave sales rep was in my office two weeks ago and commented that I may be the only doctor in the Country who has all 3 top shockwave deices.
Please call 310-444-9393 for an appointment
Shockwave therapy is a non-invasive treatment. The application is simple and easy. Initiate therapy in 3 steps:
Location of the area to be treated
The area to be treated is located using palpation in order to deliver the therapy precisely.
Sufficient amount of gel is applied to the area located in step 1. Use of gel is necessary to transfer the acoustic waves efficiently and smoothly.
The Shockwave applicator is slightly pushed against the area to be treated and the start button is pressed.
If you’re suffering from a soft tissue ailment or looking for an alternative, holistic approach to pain reduction, and want overall healthy joint aging, EPAT shockwave and laser may be an effective option. Dr. Jeffrey Tucker says “The results from EPAT (shockwave) and laser are promising for acute pain, chronic pain conditions and regenerative medicine.”
Frequently asked questions about EPAT:
Is deep tissue massage similar to EPAT Shockwave? No, EPAT shockwave penetrates much deeper than hands can get. EPAT goes beyond muscles treating the underside of muscles, bones, and joints to work on a deeper level.
EPAT Shock wave sessions usually last thirty minutes! True, they normally take about 20-30 minutes depending on the number of impulses and the number of areas we are intending to apply to a given area.
Some patients describe the EPAT as a ‘Jack hammer’. Why? The overall feeling is a combination of gliding, kneading, percussion, vibration, deep friction massage, and rolling of the soft tissue and joints.
EPAT is often used in combination with other therapies including laser, deep muscle stimulator (DMS) and cupping.
Like most massage, EPAT is traditionally practiced on exposed skin surfaces. You should wear loose, comfortable clothing to ensure the doctor can have skin exposure and be able to move your joints through the full range of motion. During EPAT therapy, ultrasound gel is used on treatment surfaces.
Dr. Tucker’s philosophy treats patients holistically, focusing on physical, mental, nutritional and healthy aging wellness. “I help achieve joint and muscle balance using a blend of modern technology like the Deep Muscle Stimulator (DMS), Laser, EPAT (shock wave) and therapies that have stood the test of time like cupping and transverse friction massage.
“I have every intention of helping patients detect and correct where they may be blocking recovery by mental and physical tension, bad habits, and the poor health they showed up with if that is the case.”
In this study patients with chronic low back pain who followed cognitive intervention and exercise programs (versus surgery) improved signi?cantly in muscle strength compared with patients who underwent lumbar fusion. In the lumbar fusion group, muscle density (meaning ‘weak muscles’) decreased signi?cantly at L3–L4 compared with the exercise group.1
In addition to exercise therapy for chronic low back pain, current treatments include laser therapy and shockwave therapy for spinal problems, especially when scar tissue has formed. If you have damaged spinal ligaments causing spinal instability or ‘Enthesopathy’ (areas of irritable ligament attachment to bone) a trial of exercise and laser is highly recommended.
Dr. Jeffrey Tucker has created new treatments combining laser therapy, shockwave therapy and exercise to stimulate stem cell activity. Most up-to-date doctors agree that treating back pain patients with conservative care is better than injections or surgery. Doctors that understand how to treat chronic low back pain such as degenerative disc disease, address the problems of spinal ligament instability and scar tissue formation by stimulating the body’s natural ability to regenerate the discs indirectly – decrease spinal stiffness, increase paraspinal muscle activation/strength, and increase hydration in the discs.2 This approach helps decrease pain in the low back.
Please feel free to call my office for a consultation 310-444-9393
- Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikerås O. Trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine (Phila Pa 1976). 2004 Jan 1;29(1):3-8.
- Röllinghoff M, Schlüter-Brust K, Groos D, et al. Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine. Orthopedic Reviews. 2010;2(1):e3.
West Los Angeles Chiropractor
Patients who are thinking about spinal injections or surgery, or have had spinal surgery (fusion, disc procedure, etc.) should see a Chiropractor trained in proper exercise therapy and who uses laser therapy and other new technology such as acoustic wave therapy to improve spinal strength and stability. In addition, scar tissue and muscle atrophy needs to be evaluated and treated. This can help prevent costly and risky injections and surgery.
Why is failed back surgery syndrome so common? Researchers at the Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University in Japan:
Up to 25% of patients report unimproved or worse pain and up to 40% are not happy with the outcome of lumbar fusion.
The possible reasons for poor results include instrumentation failure, inadequate surgical technique, and poor patient selection.
In patients who had continued pain after back surgery, muscle biopsies revealed:
Atrophy of paraspinal muscles
Loss of muscular support leading to disability and increased biomechanical strain and possibly failed back syndrome.1
In another study researchers found that the muscles adjacent to the fusion (the paraspinal muscles of the lumbar spine) play an important role in recovery. The muscles become weak and unstable after a spinal fusion.2 If those muscles remain damaged or weakened, the spine is unstable and pain persists.2
I can’t say enough about this…Doctors at Oslo University Hospital examined patients who had continued pain 7 to 11 years after spinal fusion. They found reduced muscle strength and density of tissue one year after lumbar fusion: 27% reduction in muscle density.3 Again, patients need a skilled practitioner like myself to help them properly build strength and stability…but I recommend doing this before injections or surgery if at all possible.
1 Ohtori S, Orita S, Yamauchi K, et al. Classification of Chronic Back Muscle Degeneration after Spinal Surgery and Its Relationship with Low Back Pain. Asian Spine Journal. 2016;10(3):516-521.
2 Malakoutian M, Street J, Wilke HJ, Stavness I, Dvorak M, Fels S, Oxland T. Role of muscle damage on loading at the level adjacent to a lumbar spine fusion: a biomechanical analysis. Eur Spine J. 2016 Sep;25(9):2929-37.
3 Froholdt A, Holm I, Keller A, Gunderson RB, Reikeraas O, Brox JI. No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises. Spine J. 2011 Aug;11(8):718-25.
Both Shockwave and laser help damaged disc and bulges by:
- Stem cell activation: Stem cells are effective in inhibiting disc degeneration and disc herniation. It’s a pretty complex interplay between the stem cells and the immune system cells but the result can be disc tissue regeneration.
- Stem cell activation: This will promote regeneration of the outer tissue of the disc and help contain and lessen the bulge (scar tissue formation).
- Stem cell activation:The increased number of cells to the area brings more oxygen to the damaged disc and accelerates healing by reversing the low-oxygen (degenerative or dying) environment in the spine. Everything heals better and faster with increased oxygen.
- Stem cell activation reduces and prevents herniation by suppressing the non-healing inflammation.
Office phone 310-444-9393
References: Cunha C, Almeida CR, Almeida MI, Silva AM, Molinos M, Lamas S, Pereira CL, Teixeira GQ, Monteiro AT, Santos SG, Gonçalves RM, Barbosa MA. Systemic Delivery of Bone Marrow Mesenchymal Stem Cells for In Situ Intervertebral Disc Regeneration. Stem Cells Transl Med. 2016 Oct 11. pii: sctm.2016-0033.
- Arthroscopy Journal 2015 – doctors concluded that PRP injections are a viable treatment for knee osteoarthritis and should be considered in patients with knee osteoarthritis.6 Studies like these add to the accumulating evidence that PRP can halt and reverse meniscus degeneration.7,8
- J Orthop Res. 2016 – doctors confirm that stem cell therapy stimulates the regeneration of meniscal tissue. Specifically with regard to post-meniscectomy meniscus growth (with stem cells).9 This means we can use the PIEZOWAVE and EnPuls to stimulate regeneration even after surgery.
- Doctors at the University of Iowa found that stem cells and cartilage cells could be influenced to migrate to the site of “white-zone” where the most difficult meniscus tears are. I use Laser therapy, PiezoWave Pulse Therapy and EnPuls shockwave to do just that!
- I do think stimulating the tissues with PiezoWave and EnPuls shockwave can promote regeneration and is a promising new strategy in meniscus repair.10
- Stimulating stem cell based strategies for meniscus tissue is a fundamental role in meniscal regeneration.
- Pihl K, Roos EM, Nissen N, JøRgensen U, Schjerning J, Thorlund JB. Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery. Acta Orthop. 2016 Sep 13:1-7.
- Brelin AM, Rue JP. Return to Play Following Meniscus Surgery. Clin Sports Med. 2016 Oct;35(4):669-78. doi: 10.1016/j.csm.2016.05.010. Epub 2016 Jul 9. Review.
- Noyes FR, Barber-Westin SD. Long-term Survivorship and Function of Meniscus Transplantation. Am J Sports Med. 2016 Sep;44(9):2330-8.
- Niu W, Guo W, Han S, Zhu Y, Liu S, Guo Q. Cell-Based Strategies for Meniscus Tissue Engineering. Stem Cells International. 2016;2016:4717184. doi:10.1155/2016/4717184.
- Blanke F, Vavken P, Haenle M, von Wehren L, Pagenstert G, Majewski M. Percutaneous injections of Platelet rich plasma for treatment of intrasubstance meniscal lesions. Muscles Ligaments Tendons J. 2015 Oct 20;5(3):162-166.
- Campbell KA, Saltzman BM, Mascarenhas R, Khair MM, Verma NN, Bach BR Jr, Cole BJ. A Systematic Review of Overlapping Meta-analyses. Arthroscopy. 2015 Nov;31(11):2213-21. doi: 10.1016/j.arthro.2015.03.041. Epub 2015 May 29.
- Wu CC, Chen WH, Zao B, Lai PL, Lin TC, Lo HY, Shieh YH, Wu CH, Deng WP. Regenerative potentials of platelet-rich plasma enhanced by collagen in retrieving pro-inflammatory cytokine-inhibited chondrogenesis. Biomaterials. 2011 Sep;32(25):5847-54. Epub 2011 May 25.
- van Buul GM, et al. Platelet-Rich Plasma Releasate Inhibits Inflammatory Processes in Osteoarthritic Chondrocytes. Am J Sports Med. 2011 Nov;39(11):2362-70. Epub 2011 Aug 19.
- Seol D, Zhou C, Brouillette MJ, Song I, Yu Y, Choe HH, Lehman AD, Jang KW, Fredericks DC, Laughlin BJ, Martin JA. Characteristics of meniscus progenitor cells migrated from injured meniscus. J Orthop Res. 2016 Nov 3. doi: 10.1002/jor.23472.
- McCrum CL, Vangsness CT. Postmeniscectomy Meniscus Growth With Stem Cells: Where Are We Now? Sports Med Arthrosc. 2015 Sep;23(3):139-42. PUBMED Meniscus Growth With Stem Cells