Last week I had a MRI done on my shoulder and today I went back to the doc to see what the damage was. Good news! Rotator cuff not torn, just sprained. Said most of the damage was bursitis, cause from 'old age'. Gave me a steroid shot in the shoulder and wants me to go to physical therapy. Haven't made up my mind if I'm going or not. I kinda figure working every day on the farm is about as good a physical therapy as you can get, as long as I don't overdo it, for a while.
Why don't you look into percutaneous, ultra sound guided needle tenotomy with platelet rich plasma injection? It is inexpensive, almost painless, non-surgical and highly effective.
https://www.mdpi.com/2077-0383/9/7/2114/htmFrom the study....
4. Discussion
Our main findings are that US-guided percutaneous tenotomy of the LHBT is a procedure with 100% technical success and technique efficacy, high degree of patient’s satisfaction and no immediate complications.
This prospective study is the first cases series in living patients. Looking at the technical side of the procedure, previous feasibility studies on cadavers tested different approaches to sever the LHBT. In the first series published by Levy et al. [33], the authors cut the intra-articular portion of the tendon with an anterolateral superior skin incision, 1 cm lateral and inferior to the coracoid, similarly to ours, but obtaining a successful tenotomy in only 25% of cases. However, the authors used an out-of-plane approach that can limit the efficacy of a procedure that needs to be very precise. Then, the procedure was done by a sonographer with unreported experience in image-guided interventional procedures. Further, the authors tried to cut the tendon intraarticularly, close to the anchor, a zone which is usually not well accessible using US. This point was also underlined in the cadaveric study by Sconfienza et al. who, indeed, preferred to perform the tenotomy in the most cranial part of the intertubercular groove with 100% success [32]. Aly et al. [30] performed the tenotomy on cadavers at the rotator interval using different arthroscopic scalpels, obtaining a complete tenotomy in 67% of cases. The last cadaveric study was published by Atlan and Werthel, who differently demonstrated the efficacy of an endoscopic backward cutter using a posterior arthroscopic portal [31]. In the only one case reported on living patient, the authors used a #10 scalpel for skin incision and an arthroscopic trigger finger release hook knife to cut the extra-articular portion of the LHBT between the distal edge of the subscapularis tendon and the proximal edge of the pectoralis major tendon [35]. Their patient experienced pain relief and was able to return to normal level of activity, with the proximal tendon stump still placed at the proximal portion of the intertubercular groove at follow-up US examination. In our study, we preferred to do an anterosuperior skin incision in order to cut the LHBT at the rotator interval as medial as possible and with an in-plane approach to continuously monitor the scalpel advancement. Our choice was dictated by several reasons. Indeed, despite the poor success rate of Levy et al., the rotator interval can be easily scanned by moving the patient arm [22,39] and the in-plane approach helped us to precisely cut the tendon reducing the risk of iatrogenic injuries. Cutting the LHBT as medial as possible allowed us to keep at minimum the length of the proximal tendon stump, which may potentially impinge inside the joint. In addition, we avoided the distal approach tested by Greditzer et al. [20] to decrease the risk of damage to the crossing fibers of the subscapularis tendon and to the recurrent branch of the circumflex artery of the humerus.
Our procedure had very high overall patient satisfaction rate, with 91% of patients being satisfied or very satisfied at follow-up examination. Only one patient was neutral and was also the only one presenting Popeye deformity, cramping once per week and very minimal pain in the biceps muscle. Furthermore, all patients experienced pain relief and would have their percutaneous tenotomy again, with neither weakness in elbow flexion nor limitation in daily activities due to the biceps. These results are in line with those reported by Meeks et al. who administered the same questionnaire to 104 patients subjected to arthroscopic biceps tenotomy [42]. Ninety-one percent of their patients were satisfied/very satisfied, 95% would have the tenotomy again, 13% had the Popeye deformity, and about 20% presented cramping once per week and very minimal pain in the biceps muscle. The low frequency of Popeye deformity could be related to our approach. Indeed, we cut the LHBT as medial as possible into the rotator interval thereby decreasing the risk of both Popeye sign and intra-articular impingement of the proximal tendon stump. On the other hand, we can postulate that a high percentage of arm fat could have left invisible the biceps deformity. However, we have not available data regarding body mass index or other measures of body fat percentage. We also found similar results in terms of pain relief to those reported in a recent study aimed to compare arthroscopic tenotomy and tenodesis [18]; indeed, the authors reported pre-tenotomy mean VAS of 7.5 (which was about 8 in our series) and post-tenotomy mean VAS of 4 (which was around 3 in our series). In this regard, it is important to highlight the main differences between arthroscopic tenotomy and our novel procedure. Arthroscopy needs to be performed in operating room with a team composed of orthopedist, nurse and anesthesiologist. It requires two skin incisions and regional anesthesia, it is a more-invasive and longer procedure. Conversely, US-guided tenotomy can be performed in dedicated interventional rooms or ultrasonography rooms and it involves a radiologist and a nurse. Further, it has shorter procedural time and requires only one mini-incision and local anesthesia.
No major complications were encountered, and the procedures were no painful with no significant bleeding. Indeed, although lidocaine is generally used for local anesthesia prior to US-guided musculoskeletal procedures [29,38], we preferred to use a solution of mepivacaine + adrenaline to reduce the risk of bleeding due to the relatively invasiveness of the procedure. Further, the percutaneous tenotomy led to a minimal skin incision and was very quick, requiring a mean time of about one minute from skin incision to scalpel retraction, in line with a previous feasibility study on cadavers where the mean elapsed time was 53 sec [32]. Notably, two minor complications were observed in our series. One patient complained of shoulder pain due to subacromial-subdeltoid bursitis, which was successfully treated with a single bursal injection of steroid. Moreover, we encountered a delayed wound healing in a diabetic patient, which then resolved spontaneously. It is well known that wounds can take longer to heal in patients with diabetes. Thus, we recommend reducing to a minimum skin incision paying particular attention to skin disinfection in case of uncontrolled diabetes in order to decrease the risk of delayed wound healing and infections.
Some limitations should be taken into account. First, our sample size was relatively small, although it was enough according to sample size calculation and it was sufficient to reach statistically significant results. Nevertheless, larger studies will enable to better understand the real frequency of complications related to this procedure. Then, this is a prospective non-controlled study, thus we did not compare the results of our procedure with those of arthroscopic surgery that is considered the standard of care. However, US-guided LHBT tenotomy was never tested before on living patients, thus a feasibility study was needed. We acknowledge that the shorter procedural time and higher cost-effectiveness of US-guided tenotomy do not require any comparison with arthroscopy. Nevertheless, future prospective randomized trial should be aimed at comparing our novel procedure to standard arthroscopy to understand the relevance of possible iatrogenic injuries to joint cartilage and RC tendons, as well as to assess the risk of intra-articular impingement related to the proximal LHBT stump and the clinical impact of possible missed diagnosis normally reached during arthroscopy. Last, we used a not validated questionnaire for follow-up clinical evaluation based on what previously published [42]. However, similarly to Meeks et al. we aimed at providing a biceps-specific questionnaire to assess clinical outcomes after tenotomy.
In conclusion, US-guided percutaneous tenotomy of the LHBT has 100% technical success and technique efficacy, high degree of patient’s satisfaction and no immediate complications. Future prospective randomized studies comparing the outcome of this procedure with the standard of care are warranted.
