Shoulder Pain

Tags

deltoid, Generalized DJD, glenohumerl joint, infraspinatus, pmr, radiculopathy, rotator cuff, shoulder, subacromial, subdeltoid, supraspinatus, tendonitis

Shoulder is a complicated joint as it involves three bones and four articulations. It is also not a usual place for arthritis and therefore cause of shoulder pain requires prompt investigation. 

Shoulder pain can be either inflammatory or it could be structural. Shoulder inflammation often causes pain at night and is better with activity during the day. These include: 
– Polymyalgia Rheumatica 
– Rheumatoid Arthritis 
– Seronegative Arthritis 

Structural shoulder problems on the other hand cause pain mostly during the day and also at night. These include: 
– Bursitis 
– Tendonitis 
– Rotator Cuff tear 
– Shoulder impingement 
– Frozen shoulder 
– Osteoarthritis
– Scapulothoracic syndrome
– Neck pain radiating into the shoulder

Evaluation usually involves
– physical examination
– X-rays
– MRI exam
– Local injection with Marcaine to determine the cause of pain in selected cases

Treatment depends on the specific cause and can range from exercise to medication and at time surgery.
– Polymyalgia Rheumatica: Diagnosed by a short trial of steroids. It is treated by Methotrexate or long term low dose prednisone with gradual taper.
– Rheumatoid Arthritis: Diagnosed by a short trial of steroids as well. It is treated by Methotrexate as well as other drugs listed.
– Seronegative Arthritis. These may not respond to steroids. They would usually do respond to NSAIDs.

Structural shoulder problems on the other hand cause pain mostly during the day and also at night. These include:
– Bursitis
– Tendonitis
– Rotator Cuff tear
– Shoulder impingement
– Frozen shoulder
– Osteoarthritis
– Scapulothoracic syndrome
– Neck pain radiating into the shoulder

Temporomandibular problems or TMJ

Tags

bruxism, dentist, jaw, mandible, Neck pain, oral surgeon, physical therapy, rheumatologist, splint, teeth, TMJ

1. TMJ problems are not uncommon. The first step here, once you rule out obvious causes, is to see a general dentist and not an oral surgeon. If the general dentist indicate that this is not a dental issue, then I will proceed with further evaluation.

2. MRI I believe is the best imaging modality to look at TMJ. X-rays may show arthritis or dental issues but MRI will give you the best detail.

3. TMJ problems often can be solved once the cause is identified and treated. Treatment include self care activities such as eating soft food, avoiding chewing gum, exercise, relaxation, use of splint, and medications. I have not found physical therapy to be helpful with treatment of TMJ.

4. Surgery should be avoided if possible. Always ask for MRI first especially if surgery is being considered. No one I believe should be operated on without having an MRI first. Also, find another independent oral surgeon yourself in another town or preferably at a university setting to get a second opinion if surgery is being considered.

5. If still not sure, see a rheumatologist who can do the work-up for you and make a proper referral if needed.

Newest drug for treatment of osteoporosis!

Tags

alendronate, ostecoclast, osteoblast, romosozumab, sclerostin, teriparatide

Romosozumab is the newest agent for treatment of osteoporosis that appears to be far more effective than FOSAMAX (alendronate) and even more effective than Forteo (teriparatide) based on a recent study. It was not compared to the other monoclonal antibody on the market PROLIA possibly because they are both made by the same company.

This medication was given by injection every month and also every three months. A newer drug for osteoporosis has been long overdue and being an injectable given every month or every three months should improve compliance.

Hopefully this drug is priced similar to Prolia and not Forteo which is five times more expensive.

Most effective drug on the market today is still Forteo.

Prolia effective up to eight years for treatment of Osteoporosis!

Tags

Actonel, and Reclast, biphosphonates, bone loss, Boniva, DEXA, Fosamax, fracture, osteopenia, Prolia, t score

Prolia, an injectable drug used for treatment of osteoporosis, was shown to remain effective for up to eight years based on recent data presented.

This is certainly better than the current recommendations limiting the use of treatments with biphosphonatesg such as Fosamax, Actonel, Boniva, and Reclast to five years for lack of data.

In other words you could lose almost a third of your bone density and still have normal looking x-rays.!

Tags

Actonel, alendronate, bone loss, Boniva, denosumab, DEXA, Dual-Energy X-ray Absorptiometry, estrogen, Evista, Fosamax, Fosamax D) risedronate, ibandronate, osteoporosis, Prolia, raloxifene, Reclast, Zoledronic acid

Osteoporosis or Bone Loss can not be detected on routine X-rays unless you have lost 40 percent of your bone density.

In other words you could lose almost a third of your bone density and still have normal looking x-rays.

Therefore, if you want to know if you indeed have lost bone, you should obtain a DEXA examination.

DEXA or Dual-Energy X-ray Absorptiometry is a scanning technique using extremely low radiation exposure to determine bone density with Significant precision.

Metal-on-metal hip implants

Tags

chromium, cobalt, Diabetes, Hip replacement, immune suppression, metal ion, nickel, obesity, steroids

The seven points to remember about metal-on-metal implants:

1. There are now FDA guidelines regarding these implants.

2. MoM hip systems should not be implanted in those with kidney failure, metal sensitivity to cobalt, chromium, nickel, immune suppressed patients, those on high dose steroids, and women of childbearing age.

3. Potential risks with with metal-on-metal hip implants according to FDA include:
Infection
Loosening
Dislocation
Osteolysis
Bone or device fracture
Elevated metal ion levels in the joint and blood
Transplacental transport of metal ions
Development of local inflammatory reactions and lesions including soft tissue masses and tissue necrosis
Development of potential systemic events related to elevated metal ion levels
Revision surgery
Femoral neck fracture (for hip resurfacing)

4. Those patients at risk for problems with metal-on-metal hip implants according to FDA
include:
Patients with bilateral implants
Patients with resurfacing systems with small femoral heads (44mm or smaller)
Female patients
Patients receiving high doses of corticosteroids
Patients with evidence of renal insufficiency
Patients with suppressed immune systems
Patients with suboptimal alignment of device components
Patients with suspected metal sensitivity (e.g. cobalt, chromium, nickel)
Patients who are severely overweight
Patients with high levels of physical activity.

5. Local symptoms related to MoM implants is as a result of metal particles being released to tissue surrounding the hip implant causing pain, bone and soft tissue damage. As a result patients may develop pain or swelling at or near the hip, a change in walking ability, or a noise from the hip. Other local reaction include:
Hypersensitivity (allergic type reaction)
Loosening
Infection
Osteolysis (bone loss)
Aseptic lymphocytic vasculitis-associated lesions (ALVAL) (histologic reaction in surrounding tissue)
Soft tissue mass (fluid-filled or solid soft tissue mass around the replaced joint that is diagnosed radiologically)
Femoral neck fracture (for resurfacing systems)

6. Systemic reactions to MoM implants has to do with metal ions that were release are moving via blood stream to other organs causing systemic symptoms. These systemic symptoms include:

General hypersensitivity reaction (skin rash)
Cardiomyopathy
Neurological changes including sensory changes (auditory, or visual impairments)
Psychological status change (including depression or cognitive impairment)
Renal function impairment
Thyroid dysfunction (including neck discomfort, fatigue, weight gain or feeling cold).

7. Proper patient selection, correct placement, and implantation are most important in order to avoid problems with metal-on-metal implants.

M. Rezaian, MD

MRI examination

Tags

ct scan, imaging, MRI, radiology, X-ray

Seven points to consider about MRI testing:

1. Sixty four percent of patients with no history of back pain had abnormal MRI exam. This simply means just because you see a herniated disc on an MRI, this does not necessarily mean the herniated disc is the cause of the back pain.

2. History and physical exam is the key to decide on the cause of the back pain. Therefore MRI should be interpreted in the context of history and physical exam.

3. A neurological exam by a neurologist not a neurosurgeon would be worthwhile when looking at severe back pain with possibility of surgery.

4. A radiologist who is fellowship trained in MRI would be most qualified to read your MRI exam. Always ask who will be reading your MRI.

5. MRI of hands and feet should be read by a fellowship trained radiologist in MRI as these are difficult to read and requires much experience.

6. X-ray examination should be done before MRI exam as X-rays may reveal enough information that MRI may no longer be necessary.

7. MRI exams are expensive therefore only specialists should be allowed to order these tests.

M. Rezaian, MD