Monday, May 12, 2025

Successful stretching for the stiff shoulder.

A few words at the start:

(1) Here I show a basic approach to stretching for the shoulder that has limited range of motion (i.e. stiffness of the glenohumeral joint). Note that in this post we'll be using the classic illustrations drawn by Steven B. Lippitt.

(2) Often the stiff shoulder has limited motion in multiple directions (shown below for a stiff right shoulder)

Forward Flexion

Abduction


External Rotation


External Rotation in Abduction


Internal Rotation in Abuction



Internal Rotation Up the Back


Cross Body Adduction

(3) Before starting the exercises, the patient should check with the treating physician to make sure they are safe and appropriate. This is especially the case after surgical procedures when tendons, muscles or bone have been repaired. 

(4)  Stretching is most likely to be successful if the joint surfaces of the shoulder are smooth - rather than when there is significant arthritis. However, these exercises may be helpful with mild-moderate arthritis.

(5) Stretching exercises are designed to restore flexibility of the fibrous tissue that surrounds the joint - the capsule - the dark tissue shown surrounding the socket on this view of the inside of the shoulder


(6) These exercises can be effectively carried out by the patient without a therapist (once the physician has given the OK). The exercises shown here require minimal equipment and can be done just about anywhere. Relaxation and patience are essential, however.

(7) For each exercise shown, the stiff arm is helped with the arm on the opposite side so that the muscles around the stiff shoulder can completely relax. The arm is moved to the point where tightness is felt and held there for a minute by the clock during which time a gentle stretch is applied while the muscles remain relaxed. Three sets of the stretches are performed three times a day, striving to make a small, but noticeable gain in the range of motion each time.

(7) Any discomfort from the stretching exercises should subside within 20 minutes. If pain lingers longer than than, the exercises should be performed with less vigor, but still continued regularly.

(8) Here are the basic stretches. I've included links to videos I put together a while back.

Assisted Forward Flexion

Video: Forward Elevation: Supine


The Forward Lean





The Sideways Lean




The Sleeper Stretch



Cross Body Adduction



Up the Back Stretch




Some patients point out that I'm not smiling in the videos.

Perhaps the photo I took last week of a yellow-headed back bird surrounded by bugs will put a smile on your face.


You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).





Saturday, May 10, 2025

Our orthopaedic judgment is flawed by noise

Recently, I posted on the surgical relevance of Daniel Kahnemann's well-known book, Thinking Fast and Slow and even more recently on his concept of "objective ignorance" in making predictions of treatment outcomes.

Now let's look at his last major book before his death one year ago by assisted suicide in Nunningen, Switzerland, choosing to end his life while still in relatively good health to avoid the potential suffering associated with aging.


He pointed out that where there is judgment, there is error. 

Two contributors to error can be illustrated by the kicker's judgment exercised when trying for a field goal. 
On the left we see Bias, a predictable, consistent deviation in a particular direction - perhaps due to wind direction, or way the holder positions the ball.
On the right we see Noiseimprecision, inconsistency, unpredictability, the lack of reproducibility. 


An important difference between these two sources of error is that bias can be identified and corrected (by directing the kick a bit windward or changing the holder's positioning of the ball). The inconsistency of noise makes it harder to fix (why does the ball go too far to the left sometimes and too far to the right on other occasions?).

BIAS

What about bias in orthopaedic practice? Here are some possible examples:

*financial bias: a surgeon may consistently recommend surgery more often than non-operative care because surgery pays better.

*practice bias: surgeons working in the Kaiser system, a Veterans' Administration hospital, a private practice, a Public Health Service hospital and an academic medical center may be subject to consistent but different influences on how they practice. This type of bias may be further influenced by ownership of a surgery center, MRI, or PT facility and by the incentive system of the practice (whether based on dollars collected or on Relative Value Units (RVU)). 

*selection bias: a surgeon may consistently favor different treatments depending on the patients' age, sex, ethnicity, or insurance (private, workers' compensation, medicaid, medicare, self-pay).

*training bias: surgeons having completed a sports medicine bias have been shown to be more likely to perform reverse total shoulders for cuff intact glenohumeral arthritis than surgeons having completed a shoulder fellowship.

*familiarity bias: surgeons may be more comfortable with an open bone block for instability associated with glenoid deficiency than with arthroscopic iliac crest grafting. 

*availability bias: the tendency to treat a patient based on their similarity to a recent case rather than on the surgeon's overall experience.

*hindsight bias: distortion of judgment so that outcomes that could not have been anticipated appear easily "foreseeable" in retrospect.

There are circumstances in which bias is appropriate and necessary. It seems best of these biases can be stated in terms of rules. Rules can shared with patients so they do not feel that decisions are being made randomly.  Here are some possible examples:

*Degenerative cuff tears are not considered for surgery until after 6 weeks of a defined therapy program

*Elective arthroplasty is not performed within 3 months of an intra-articular corticosteriod injection, or on patients who are actively smoking or on patients that do not have an adequate post discharge support system.


NOISE

A certain amount of noise may be acceptable. While this kicker's performance shows some noise, each kick landed in between the uprights. 

Kahnemann refers to this as the "valley of the normal", meaning that outcomes within the valley are OK but those outside the valley are undesirable. Some examples: insertion of an implant within 4 degrees of the desired position can lead to good function; however when the implant is in 20 degrees of varus or valgus, the outcomes can be disastrous. 

Importantly, the effects of noise do not cancel out. The average position of the six kicks is right in the middle of the uprights, but only 2 of the 6 kicks resulted in points for the kicker's team.

Varus and valgus errors do not cancel each other out either. 10 too tight shoulders and 10 too loose shoulders are not perfect on the average.

Kahnemann manages this phenomenon by using the mean of squared errors (MSE). The magnitude of each error is squared. This has two benefits: (1) the direction of the error doesn't matter (an error of +5 degrees gets the same weight as an error of -5 degrees) and (2) larger errors have a much greater effect on the mean than small errors.

Consider two surgeons. Note that they both have average errors in implant position of zero. However, because of the small magnitude of Surgeon A's errors, the mean of her squared errors is almost a tenth of the MSE for Surgeon B (who brags that his implants are, on average, in perfect position). Who would you have your relative see?


We can only conclude that noise is never good and that the ill effects of noise rise rapidly with the amount of individual deviation from the target.

Kahneman points out several types of noise

System noise – total amount of imprecision – the degree to which the treatment decisions vary – either within a surgeon (day 1 vs day 2) or among surgeons (A vs B)

Pattern noise – variations among the treatments different surgeons select for a given diagnosis. When a patient solicits a second opinion from a surgeon who is unaware of the first surgeon's opinion, the two opinions are unlikely to be the same. Anatomic vs reverse, PT vs surgery, ORIF vs arthroplasty, single row vs double row, biologics vs none, and so on.

Occasion noise – random differences in the treatments a surgeon selects for a diagnosis under varying circumstances (his mood, the time of day, fatigue, hunger, a recent fight with domestic partner, or the fiscal health of practice). Consider the following chart regarding judgments by two surgeons in the treatment of osteoarthritis with an intact cuff, cuff tear arthropathy with pseudoparalysis, cuff tear arthropathy without pseudoparalysis, massive irreparable cuff tear with pseudoparalysis and massive irreparable cuff tear without pseudoparalysis. 

1 Note that there is substantial system noise (patients with the same diagnosis are getting different treatments). 

2 Note that the patterns of the two surgeons are level but different. 

3 Note that on different occasions an individual surgeon selects different treatments for the diagnosis.

 


It is understandable that this noise causes confusion on what to do for whom.

Our American Academy of Orthopaedic Surgeons has tried to come up with practice guidelines or "Appropriate Use Criteria (AUC)", but the results are not always helpful because of noise.

Here are three examples regarding the treatment of rotator cuff tears.


(1) Use of biologics (e.g., PRP) to improve healing: Limited and conflicting evidence; no strong recommendation for or against.

(2) Early vs delayed surgery in chronic tears: Evidence is limited; clinical judgment is important.

(3) Tendon transfers (e.g., latissimus dorsi, lower trapezius) for massive irreparable tears in younger active patients: Evidence limited; decision individualized.

One final point, not only does noise complicate decisions made by patients and by surgeons, it also complicates clinical research: if each case is a "one of" receiving "individualized" management based on their particular surgeon's judgment, how can we learn what works best for which diagnoses in which patients?


Let me end this noisy post with a final salute to the mothers of the world. Here's a photo of a red tailed hawk mom tending her chicks that I took on a recent trip to the Malheur National Wildlife Refuge in Oregon. 



Here are some additional thoughts occasioned by a re-reading of this treasure.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link


Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).


Saturday, May 3, 2025

The challenge of long-term followup in orthopaedics: diminishing returns.

Patients considering orthopaedic surgery want their surgeon to predict the long-term outcomes for the procedure they are being offered: how long will it last? what are the chances of complications? how likely is it that a revision will be necessary? As pointed out in Objective ignorance - a problem in predicting outcomes in climbing and in orthopaedic surgery, average data from long-term followup studies of similar procedures performed in the past can be presented to the patient, but these averages do not predict the outcome for that individual.

There is another problem with using long-term followup studies in an attempt to predict future patient outcomes: this can be referred to as "diminishing returns". 

By this I mean that the longer the period of followup:

(1) the percentage of the initial patient cohort that is lost to followup increases progressively (perhaps because the patients were dissatisfied and transferred their care to another surgeon, or because they had a revision that truncated the followup of their initial surgery, or because they could not afford to return for followup or because they got tired of returning questionnaires or because they became ill or expired).

(2) the procedures performed a while back become progressively less representative of what is being performed currently (the patient selection, surgical techniques and implants, and surgeons evolve progressively over the time interval)

(3) the measures of patient comfort and function are inconsistent.

(4) patients having complications and revisions have a tendency to get lost or omitted for one reason or another.

(5) the number of patients included in long term followup studies is a very small (non-representative) sample of the total number of the patients currently having the procedure 

To see these factors in action, let's look at a recent article, Long-Term Outcomes Following Reverse Total Shoulder Arthroplasty A Systematic Review with a Minimum Follow-Up of 10 Years



The means of followup were inconsistent: Four studies conducted all follow-ups in a clinical setting, while 3 used either outpatient visits (20 to 41%) or phone/mail interviews. The absolute Constant score (CS) was used 5 studies. The relative CS was used in 3 studies. The Subjective Shoulder Value was used in 2 studies. The American Shoulder and Elbow Surgeons Score was used in 1 study. The Single Assessment Numeric Evaluation was used in 1 study. 

The weighted mean reported revision-free implant survivorship reported in 5 studies was 88% at 10 years; the complication rate was 36% with need for further revision in 23% of patients. However, because almost two thirds (63%) of the patients were lost to follow-up, we must suspect that the 37% of patients with followup were not representative of the total group.

Note that this study reviewed 469 rTSA procedures in 460 patients. Compare that number to the data in The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty which found that 63,845 rTSAs were performed in 2017 with projected volume increases by the linear and Poisson models of 87.9% and 353.0%, to an estimated 119,994 and 289,193 procedures in 2025. Thus the total number of rTSAs in the entire Systematic Review was less than 0.25% of the estimated current annual volume of rTSAs - we must ask whether this is a representative sample. 

The authors concluded that "rTSA appears to provide substantial long-term improvements in shoulder function, clinical outcomes, and pain relief, albeit with significant complication and revision rates. However, caution is warranted when interpreting the data due to high lost-to-follow-up rates and limited data quality in the contemporary literature".

In a salute to all mothers on Mothers' Day (May 11), here is my photo of a mother hummingbird feeding her chicks.




You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).


Friday, May 2, 2025

Back to big wave surfing a year after a stemless chrome cobalt ream and run

 A 50 year old active man from a few states south of us presented with a painful right shoulder that prevented him from enjoying his favorite sport - surfing the big waves. Two shoulder surgeons had told him he'd likely need to stop surfing.

His x-rays at the time of our clinic visit (shown below) show advanced osteoarthritis of the shoulder.

Wishing to avoid the risks and limitations that can be associated with the polyethylene glenoid component used in conventional total shoulder, he elected to proceed with a ream and run arthroplasty.

His procedure was performed without preoperative CT scans and without a nerve block. The shoulder was exposed with a subscapularis peel. The biceps tendon was preserved and the glenoid was conservatively reamed without attempt to modify version. A stemless chrome-cobalt humeral component was implanted.

His postoperative x-rays are shown below. 


We recently received this note, "Just wanted to share with you how happy I am with the results of my Ream and Run operation from April 9, 2024. To celebrate the one-year mark, I took a surf trip to El Salvador and was able surf 3 - 5 hour every day with no pain. I’m so grateful to be able to return to the activities I enjoy. 

He shared the photo below from his El Salvador trip.





You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).


Saturday, April 26, 2025

Objective ignorance - a problem in predicting outcomes in climbing and in orthopaedic surgery


Mount Rainier is a popular climbing destination. Approximately 10,000 registered climbers attempt to reach its 14,000 foot summit each year. From the graph below we can see that the base rate for fatalities among these climbers averages about 3 per ten thousand (0.3 per thousand). However, the per year rate varies substantially. We are unable to predict the death rate for the coming year because we cannot anticipate what factors will contribute to the death rate in 2026. Daniel Kaheman refers to this as "objective ignorance".


A striking example of our inability to predict the occurrence of climbing deaths was in 1981when an avalanche killed 11 Rainier climbers. 

This event stands as the deadliest mountaineering accident in U.S. history.​ On that day, a group of 29 climbers, including guides and clients from Rainier Mountaineering Inc., were ascending the Ingraham Glacier route. At approximately 5:45 a.m., a massive serac—an unstable block of glacial ice—broke loose from the upper Ingraham Glacier, triggering an avalanche of ice and snow. The avalanche swept through the climbers' resting area near Disappointment Cleaver, burying 11 individuals under tons of ice and snow. Despite extensive search efforts, the victims' bodies were never recovered and remain entombed within the glacier.

As an aside, my wife and I (and many others) safely summited Rainier by the Ingraham Glacier route both before and after that accident. 


Climbers refer to avalanches as objective hazards - dangers that exist independently of a person's actions, skill, or decisions - they are external, uncontrollable risks inherent to the environment. In this case the National Park Service Board determined "that the accident was a random event that could not have been predicted."

In orthopaedic surgery, objective ignorance keeps us from accurately predicting outcomes for our patients. As pointed out in a prior post, two year ASES scores for patients with cuff intact arthritis having reverse total shoulder arthroplasty have a base rate averaging 83 [SD 12.6]. Yet these numbers do not enable surgeons to accurately predict the result in an individual case because we are ignorant of the "random events" that could have profound effects on the outcome realized by the patient. An unexpected optimization of their social or rehabilitation support may lead an exceptionally good recovery. Conversely, the outcome is likely to be subpar after an acromial/spine stress fracture or the onset of Parkinson's Disease leading to multiple falls and dislocations. In addition, the new implants a surgeon has started to use may be found to have consistently better outcomes, or they may have a design flaw that only becomes evident months after the procedure.

The point here is that while we may know the average base rates for the outcomes of surgical procedures performed in the past, we need to be cautious about using this information to make predictions about future results for an individual patient because we are ignorant of the objective factors that may affect that person's outcome. 

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).


Thursday, April 24, 2025

How to select a research project - my thoughts

Many of us want to do shoulder research - it is engaging, holds promise for improving our understanding and care of our patients, and helps in career advancement. 

Because good research requires substantial effort and funding, it is important to make good choices. 

In selecting a project with high probability of success, three elements need consideration:

1. Can the question be stated clearly in quantitative terms?

2. Why is this question important?

3. Is the study doable?

Let's consider an example regarding the clinical value of 3D planning for reverse total shoulder arthroplasty for patients with primary osteoarthritis



1. Can the question be stated clearly in quantitative terms?

In a trial controlling for important confounders, does the use of preoperative CT-based planning for patients having primary reverse total shoulder arthroplasty for arthritis improve the two-year postoperative American Shoulder and Elbow Surgeons (ASES) scores by the clinically significant amount of 20.9 in comparison to comparable patients having reverse total shoulder arthroplasty without 3D CT planning.

2. Why is this question important?

Because obtaining advanced imaging and using planning software involves increased time, expense and additional radiation exposure, surgeons and patients should be able to consider the benefit of these technologies to the patient in comparison to their costs. 

3. Is the study doable?

The recently published two year ASES scores for patients with cuff intact arthritis having reverse total shoulder arthroplasty averaged 83 [SD 12.6]. In that the maximum ASES score is 100, there are only 17 points of possible improvement before the ceiling is encountered. Since the minimal clinically important difference is 20.9, it would not be possible to show a clinically significant benefit to the patient of 3D CT based planning using the ASES score as the outcome of interest.

Thus while the question can be stated in quantitative terms and is clinically important, the proposed study is unlikely to provide the desired information.

Students, residents, fellows and faculty come up with ideas for research projects. We've found that tasking them with answering these three questions helps them make good choices for a productive research experience.


House finch making good choices

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).