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s an M.D. specializing in Regenerative Medicine and sports injuries, I commonly see patients with shoulder problems. This is perhaps the third most common presenting complaint I encounter (after knee and back issues).
Shoulder problems are common because the joint is so shallow and totally dependent on the ligaments and surrounding muscles (rotator cuff) to give it stability. Unfortunately, MRI is of limited value in the evaluation of shoulder injuries. It does pick up large rotator cuff tears but often misses problems with the underlying capsule and the more subtle sprains and strains, which are so commonly the root-cause of pan and dysfunction.
As always with Regenerative Medicine a proper examination is the key to correct diagnosis. I usually start the evaluation by observing the range of motion. If abduction (lifting laterally) is limited the patient may have so-called entrapment syndrome where the superior labrum is involved. It is also common to have internal rotation restricted.
The next step is to palpate specific structures to see where I elicit the “Jump Sign”. The main sites I’m interested in include the AC joint, coracoid, anterior capsule, infraspinatus, teres minor/major and Levator Scapularis insertion.
After identifying the major trigger points (what I call the “epicenters” of pain) we numb the skin and then inject them as precisely as possible. We also inject the whole joint posteriorly, just to cover internal structures that we cannot reach to palpate.
There is usually some discomfort with the injections. In fact I almost always tell patients that if you have a Regenerative Medicine session and don’t feel the injections, the doctor probably missed the trigger points. They need to be injected within a dime’s size to be optimal.
If looking for a Regenerative Medicine specialist avoid “dabblers” in the field. Choose a doctor who makes connective tissue work his full time specialty. Ask them how long they have been doing this work and where they got training. A good place to start is on GetProlo.com. As a sidenote make sure they plan on injecting not only the main joint but all the appropriate surrounding ligament and tendon attachements.
At GolfInjuryMD, our success rate with rotator cuff problems is in the range of 80-85%. It usually takes four or six sessions over a couple of months to complete the healing. Personally, I like to inject patients quite aggressively to start with. As they do better and I get them “over the hump” we can afford to space sessions out. Since the healing will continue for about 6 weeks after each injection session, spacing the sessions a little allows mother nature to catch up and the healing effect of the injections can have their full effect. It also gives the patient time to evaluate and test their progress.
Assuming the correct sites have been identified and injected properly, a patient’s progress is dependent on how fast they heal. This is impossible to predict. I often have patients tell me they are fast healers. They are saying that their skin heals fast after a cut perhaps. For me, the connective tissues may be quite different in how fast they heal. Here, the blood flow is the important factor and there may be many other variables that we are not aware of.
Given the variance in healing paths, some patients will improve after a session or two, other will take four sessions before they notice anything. In Regenerative Medicine we encourage patients to not have expectations but to objectively observe their progress.
We recommend against anti-inflammatory medication and steroid injections because this interferes with the connective tissue healing. We urge movement and heat, particularly moist heat because it penetrates better i.e. hot tub, hot showers etc. Massage by therapists or by the patient themselves is helpful, particularly before activity. I usually suggest a good quality arnica gel to be applied to trigger point areas twice daily. In general, avoid weights altogether. I prefer swimming for rehab. Light band work may also be helpful.
For golfers (or tennis players for that matter), I urge them to get back to playing as soon as possible, even if they are just working with the short game. Actually, good golf should involve little stress on the shoulders, so this is a chance to improve their technique. I often suggest that golfers work with a good golf coach to optimize their swing and minimize shoulder stress.
