Are you suffering from long standing shoulder pain? It could be a torn rotator cuff

Rotator cuff is a group of four muscles located in the shoulder. They are very important for day to day activities which involves the shoulder. The shoulder is a ball and socket type of joint. The rotator cuff attaches to the ball component (humerus) of the shoulder joint. Injury or damage to the rotator cuff could be the reason why many people experience pain in the shoulder. The pain due to rotator cuff tear is normally felt on the top or outside of the shoulder. It is also very common to experience pain anywhere between the shoulder and elbow along the outer aspect. The pain typically occurs after the use of shoulder and is often quite significant at night, disturbing your sleep.

There are a number of ways a rotator cuff can be injured. A fall on the outstretched arm or a fall onto the shoulder can cause a rotator cuff injury. More commonly, a rotator cuff tears over a period of time due to degenerative changes within the tendon. People can develop arthritic changes in the joint above the shoulder (acromio-clavicular joint) at the far end of the collar bone (clavicle). When this joint becomes arthritic, spurs can protrude downwards, which can cause injury to the tendon. Other ways a rotator cuff can tear is due to overuse. This type of tears is usually seen in the athletic population who play sports like swimming, weightlifting and throwing.

Besides the pain, feeling of weakness in the arm can be an additional symptom. The weakness is typically experienced while doing an activity wherein the arm is held away from the body. If you are suffering from any of these symptoms, its advisable to see a specialist Orthopaedic surgeon.

The orthopaedic surgeon performs a through physical examination of your shoulder. If a rotator cuff tear is suspected he may request for several investigations to confirm the diagnosis. A radiograph (xray) of the shoulder will be helpful to look for the presence of  spurs and arthritis of the acromio-clavicular joint. MRI scan is a simple, non-invasive test to confirm the diagnosis of rotator cuff tear. The advantage of MRI is that it does not involve radiation exposure and it can pick up a rotator cuff tear most of the times. It clearly demonstrates the type and size of the tear and the quality of the rotator cuff tendon.

Treatment of rotator cuff tear initially includes pain medications, cold compresses and gentle exercise programmes. It is advisable to decrease the amount of overhead lifting for a few weeks. Your surgeon may offer an injection of cortisone. Cortisone helps to relieve pain by reducing the inflammation. If the pain persists or recurs after resuming normal activities, you may be a candidate for surgery.

Over the past few years, arthroscopy (key hole joint surgery) has been used to repair the torn rotator cuff. This is much less invasive way to adress the rotator cuff tear. The arthroscopic surgery involves 3-4 small incisions around the shoulder. The camera and surgical instruments are inserted through these incisions and the rotator cuff tear can be repaired. The advantage of arthroscopic surgery is less pain, minimal blood loss and quicker recovery. There is very minimal damage to the sorrounding structures and it avoids unsightedly scars. With the advent of arthroscopy, rotator cuff can be performed as a day care procedure. Following the surgery, a period of rehabilitation follows for several weeks, before you can resume your full set of activities like lifting heavy weight.

One of the problems with these tears is when the pain has been neglected for a long time. If the rotator cuff has been left torn for several months or years, they can slowly progress in size and become irrepairable. It may lead to progressive arthritis of the shoulder (rotator cuff tear arthropathy). These conditions can cause persistant pain and weakness and may need complicated procedures to be addressed. 

Is My Child Developing Well?

Development in paediatrics is an important aspect of childcare not to be confused with growth. The milestones which is the level of skill achieved is generally measured over a period of time. Often, parents get worked up not knowing that all skills are achieved over a range of months and there is not a single time set in stone, for its achievement. So what is normal in lay parlance may very well be an atypical development and vice versa.

The usage of development as normal and abnormal amounts to labeling a child and much anxiety in a parent. Instead your child could be neuro typical vs neuroatypical. Each child charts his own course and is widely determined by genetics and environment (nature and nurture)

Let me enumerate this with an anecdote. Sitting at my clinic one day, in walked a parent with a three year old boy in tow. The parent was having difficulty getting the child into the room…and once there the child could not be stopped from exploring the room. The mother a bit flustered, sat down all the while trying to get the child to behave. The child avoided eye contact and for much of the time didn’t respond to his name. He was busy opening the tap and seemingly would not understand the instructions being given by the mother. The frustration was so obvious in the mom’s eyes. Though unrelated to the child’s present complaints, on probing the mum revealed he had been recently diagnosed with autism with ADHD and they had returned from overseas to seek help as well as family support.

I enumerated this coz for anyone who can`t see the symptoms he was just a being a child an ill behaved child but for the child going out of his house,this maybe an explosion of senses, what we call the sensory issues.

So what are the flag signs in development:

When did your child achieve his first social smile?

Did he roll over, sit and stand on time?

Were there any delays in vocalization, making sounds and involving in social plays?

In the second year:

How many words does your child speak at 18 months? Does he combine two words by two years?

Does he respond to his name?

Does he ask for objects by pointing?

Does he involve in repetitive movements called “stimming”?

Does he involve in stereotypical movements spinning objects, lining objects or seem preoccupied with parts of objects?

Does your child`s behavior result in frequent meltdowns?

Does your child refuse to eat foods of certain texture?

Does visits to new places/malls/hotels turn out to be difficult experiences?

Does your child not follow your instructions?

And lastly

Socially does your infant engage in peek a boo, your child show interest in other kids?

These are a few milestones which serve as red flag for a pediatrician. A screening for autism and evaluation by a developmental pediatrician is the next step. The approach to developmental delays is multifold. Often it involves a team of paediatrician, speech therapist, occupational therapist, special educators, audiologist and physiotherapists. Your paediatrician forms the core of this team and hence an integral person to put your child s development back on track.

My advice to parents

Always believe your instinct, especially to mothers. Often there maybe family history of delays or very often doctors and family telling you it`s okay to wait. It`s not. Early intervention is the key. Brain development is the maximum in the first five years and any intervention needs to be early. Lastly being neuroatypical can come with advantages and disadvantages. Work on your child advantages and lessen the effect of disadvantages and that’s a blog for another day.

Shoulder pain due to poor posture of upper body

How many of us know about the link between poor posture of upper body and shoulder pain?

Let's see how it is linked…

The imbalance in the posture usually occurs due to

·         Poor posture awareness

·         Slouch sitting for long hours

·         Lack of proper exercises

·         Inappropriate exercise programs

·         Old Shoulder injury or shoulder pain

·         Old shoulder or upper body surgeries

The Muscles which keep the scapulae (shoulder blades) in position gradually becomes weak and elongated. The muscles opposite to them on the front of the chest gradually becomes tight and shortened. This leads to imbalance in the way body carries the shoulder. Gravity gradually pulls the shoulders forward, the scapulae flares outward, restricting the range in which the upper limb moves about. The head and neck start protruding forward. In layman terms this posture is called "rounded shoulders".

When the mechanics of the joint is hampered then the structures in and around the joint gets constricted or unnecessarily stretched leading to different types of pain syndromes, in this case, the shoulder pain. In such a situation, a trivial trauma or a sudden jerky movement can trigger a long spell of painful conditions and ultimate freezing of the movements in the joints

                         

Prudence is in getting it screened to see whether one has  poor posture which may precipitate such a painful syndrome. At Vasavi, we have highly qualified and experienced physiotherapists who can assess your posture efficiently and advise as to how to correct deviations if any.

This syndrome comprising of poor upper body posture and painful shoulders (and sometimes even painful neck) is commonly known as Upper Crossed Syndrome. 

LAPAROSCOPIC REDO BILATERAL TAPP MESH REPAIR FOLLOWING FAILED BILATERAL LAPAROSCOPIC TEP MESH REPAIR

Laparoscopic Redo Inguinal hernia repairs are fraught with challenges as the usual preperitoneal space is violated because of previous surgery and the mesh.Open inguinal hernioplasty is the standard approach for recurrent hernia following previous laparoscopic approach.There is a high risk of injury to urinary bladder and neurovascular structures in a redo laparoscopic preperitoneal approach.

60 year old male, s/p laparoscopic bilateral TEP mesh repair for bilateral inguinal hernia 7 years back presented to our hospital with swelling in the both groins since 1 year associated with occasional pain. On evaluation with USG abdomen, he was found to have bilateral recurrent inguinal hernias. We performed Laparoscopic bilateral TAPP mesh repair in a previously done laparoscopic bilateral TEP mesh repair.

The patient was discharged on 2^nd day.At 1year follow up the patient doesn’t have recurrence of hernia.

Conclusion:

Laparoscopic redo TAPP inguinal hernia repair after failed TEP can be performed; however, it should only be attempted by experts in laparoscopic inguinal hernia repair.

Does all Hernias require Surgery?

In general, hernias that are at risk for complications, that cause pain, or that limit activity should be repaired. If they are not repaired, there is a risk that an emergency surgical procedure may be required at a later date.

 Under certain circumstances the hernia may be watched and followed closely. These situations are unique to those individuals who are at high operative risks (i.e. those with severe heart or lung disease, or bleeding problems). Of course, even in the high risk person, if the symptoms become severe or if strangulation occurs, then an operation must be performed.

Serious complications from a hernia can result from the trapping of contents in the hernia -- a process called incarceration. Trapped or incarcerated tissues may have their blood supply cut off, leading to strangulation resulting in gangrene or death of the content,usually small intestine.This warrants Emergency Surgery.                                   

There is no acceptable nonsurgical medical treatment for a hernia. The use of a truss (hernia belt) can help keep the hernia from bulging but eventually will fail. The hernia will not go away without treatment; it will only get bigger. The bigger the defect the bigger the operation required to fix it.

The team of Surgeons at Vasavi hospitals are specialists in Laparoscopic repair of hernias.Patients are admitted the same day of their surgery. Following the procedure and recovery from anesthesia, they are taken to a hospital room where they spend the night. Most patients are discharged the next day following surgery. Patients are then seen, by the surgeon, one week after discharge. 

What is Rectal Prolapse?

Rectal prolapse is a condition in which the rectum or the last part of the colon protrudes or telescopes out of the anus and a variable length of rectum will be seen outside.

Poor anal tone is the main cause for this condition. Common causes of poor anal tone are age, constipation, childbirth and pelvic nerve damage .

The common symptoms of rectal prolapse are Constipation and straining, fecal incontinence, and erratic  bowel habits .

 Colonoscopy, anal manometery, colonic transit studies are often required in the evaluation of rectal prolapse.

The treatment of rectal prolapse is surgical with procedures done from the perineum and trans abdominally. 

The treatment is tailored taking into account the presence of constipation, age of the patient, need for resection of the colon and need for pelvic floor repair.

What is Gastro-esophageal reflux disease (GERD)?

                                     

Gastro-esophageal reflux disease is a backflow of acid from the stomach into the food pipe(esophagus).Although” heart burn” is often used to describe a variety of digestive problems,  it is most often secondary to gastroesophageal reflux disease.

What causes GERD?

When you eat, food travels from your mouth to your stomach through a tube called esophagus. At the lower end of the esophagus is a small ring of muscle called the lower esophageal sphincter(LES).The LES acts like a one way valve, allowing food to pass into the stomach. Normally the LES closes immediately after swallowing to prevent back-up of stomach juices, which have high acid content, into the esophagus. GERD occurs when LES does not function properly allowing acid to flow back and burn the lower esophagus. This irritates and inflames the esophagus, causing heartburn and eventually may damage the esophagus.

Who are at risk for  GERD?

GERD can afflict any person regardless of age, gender, socioeconomic status. People above 40 years, however, are greater risk of acquiring the disease.

Some people are born with a naturally weak LES. Others, however, fatty and spicy foods, smoking, drinking alcohol, vigorous exercises or change in the body position (bending over or lying down) may cause the LES to relax, causing reflux.

What are the symptoms of GERD?

•                  Heart burn (uncomfortable, rising, burning sensation behind the breast bone)
    ·         Regurgitation of gastric acid or sour contents into the mou
•                    Vomiting.                                             
•                   Chest pain- This can mimic heart attack
    ·           Difficult or painful swallowing
   ·          Bloating sensation in the abdomen

What are the complications of GERD?

When GERD is not treated, serious complications can occur such as

• Esophageal stricture-Narrowing or obstruction of the esophagus
• Barrett’s esophagus- This is premalignant change in the esophagus caused due to chronic recurrent reflux. This can lead to cancer of the esophagus in future.

Symptoms suggesting that serious damage may have already occurred include

•    Dysphagia:Difficulty in swallowing or a feeling that food is trapped behind the breast bone
•   Choking: Sensation of acid refluxed into the windpipe causing shortness of breath,coughing   or  hoarseness of voice.
•  Bleeding: Vomiting blood or passing black tarry stools
• Weight loss

How to diagnose GERD?

We take a detailed history of the patient’s symptoms and over the counter medications he has taken .If the history and our findings indicate GERD we perform the following tests to confirm GERD

• Upper GI Endoscopy:   This helps us to know the degree of damage caused by acid reflux to the lower esophagus, laxity of the LES, associated any changes in the esophageal mucosa(Barrett’s esophagus) , presence of any stricture in the lower esophagus or associated hiatus hernia.

• Esophageal manometry:·  This helps to rule out any associated Esophageal motility             disorder
• 24 hour PH monitoring: This helps to confirm the diagnosis of GERD in certain patients.

What is hiatus hernia?

This is the herniation of Gastroesophageal junction or upper part of the stomach into the thorax.

What are the treatment options available for GERD?

GERD is generally treated in 3 progressive steps

1) Drug Therapy:

 Proton pump inhibitors (PPI’S) neutralize the stomach acids and reduce the amount of stomach acid produced. Antacids also may be used for symptomatic relief. In patients with persistent symptoms , particularly aggravated at night , H2 Blockers such as Ranitidine may need to be added.

 How frequently should I take these medicines?

Once the diagnosis of GERD is established we prescribe PPI’S to be taken  twice daily and then taper it once a day , depending on severity of symptoms and endoscopic findings of severity of damage to the lower esophagus

How long should I take these medicines?

     Normally we give a course of proton pump inhibitors to be taken for 6 -12 weeks. Most patients get relieved of their symptoms with these medications and life style modifications.

   2)  Life style changes:

       These are modifications made in food and behaviours that trigger heart burn.

     This is treating GERD through self care.

      Following these simple guidelines may take care of the problem

   ·       Watch what you  eat:

   Triggers include fatty or fried foods, citrus fruits or juices, tomato sauces, spicy foods, chocolate, coffee,  peppermint , carbonated beverages and alcohol

    

   ·  Don’t gorge:

     Big meals overfills the stomach and an overstretched  stomach can increase pressure on the muscle that’s meant to keep stomach acid out of esophagus.Try 4 or 5 small snack-like meals instead of 3 large ones

   
                ·         Loose Weight:

      Extra pounds increase pressure on the stomach and forces the acid up into the esophagus. Start weight loss by increasing (low acid/non citrus) fruit, vegetables and high fiber foods in your diet. Add regular exercise.

·         Don’t Smoke:

      Tobacco inhibits saliva,the body major buffer against damage to the esophagus.Tobacco also stimulate acid production and relaxes the muscle between theesophagus and stomach,permitting acid reflux.

·         Don’t snack at bed time:

      Allow enough time for your stomach to empty before you lie down.It’s better to eat atleast 2-3 hours before bedtime

·         Raise the head of your bed:

      Gravity helps to keep acid in the stomach.Lying flat in bed makes it easier for the gastric acid to back up into the esophagus. Raising head end of your head six to eight inches can help to reduce the acid reflux.

·         Watch your posture:

      Avoid bending from waist or stooping just after meals.Eat your meals while sitting on an upright chair rather than slumped in front of the television.

       What are the indications for Surgery?

     The diagnosis of GERD and its cause must be clearly established before considering surgical approach. Unfortunately the recommended lifestyle modifications are usually ignored and although most patients with GERD can be managed adequately with proton pump inhibitors, many eventually require escalating doses over time, relapse quickly when medicines are stopped or desire to be free of medications and their significant expense. There is also a small group of patients who experience intolerable side effects of proton pump inhibitors, such as headache or diarrhoea.It is this group of patients who benefit greatly from  Anti reflux Surgery.In addition to Objective evidence of GERD the following are the indications for Surgery

      How this surgery performed?

     

    Antireflux surgery (commonly reffered to as Nissen’s Fundoplication) involves reinforcing the “valve” between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus-Much the way a bun wraps around a hot dog. About 4 cms of the intrathoracic esophagus is mobilized intraabdominally  and a tension free wrap of 1.5-2 cms of the fundus of the stomach is created at the lower end of the esophagus. We routinely perform this surgery by laparoscopic approach in which 5 tiny cuts are made over the abdominal wall to accomplish this procedure.

     How many days should I stay in the hospital? 

    Since this procedure is performed laparoscopically, there is less post operative pain, shorter hospital stay and faster return to work. Most of the patients get admitted the evening before or the morning of surgery and are discharged within a day or two following surgery.

  

     What are the complications of this surgery?

       As with any surgical procedure, there are risks associated with this surgery .

      Surgery is safe in expert hands and in hospitals with a good infrastructure and equipment.

      Some patients develop temporary difficulty swallowing immediately after the operation. This usually resolves 2-4 weeks after the surgery. Some patients report stomach bloating. Though rare in experienced hands, some patients may require a procedure to stretch the esophagus (endoscopic dilatation) or a re-operation for a failed wrap .

     What are the precautions to be followed after surgery?

     We will work with you to create a personalized treatment plan which will be given to you during your discharge from the hospital.

     Usually you should be on a liquid diet for a week following surgery in order to give time for the swelling or edema  near the wrap site to resolve.

•      Avoid carbonated  beverages and smoking
•      Chew your food slowly and thoroughly
•      Have small portions of meals
•      Do not sleep 2-3 hours after meals.

     

    When should I consult my surgeon following surgery?

     

    You will be advised to consult in the clinic 7 days following surgery. You are advised to report immediately in case of persistant fever, abdominal pain, vomiting or you are unable to eat or drink liquids.