How has minimally invasive surgery advanced in shoulder procedures?

Knee arthroscopy was the initial breakthrough, with shoulder arthroscopy being primitive in the 90s. Over time, devices evolved from metal to plastic, and now bioabsorbable tacks or braided polyester anchors are used, allowing for tiny drills and suture anchors and significantly reducing invasiveness and improving repair techniques.

What is a SLAP tear and why is it clinically relevant now?

A SLAP (Superior Labral Anterior Posterior) tear affects the superior labrum in the shoulder, initially not fully appreciated. It's now recognized as clinically relevant, especially for younger overhead athletes, weightlifters, and CrossFit participants, who can experience secondary problems if untreated.

How does shoulder anatomy contribute to its instability?

Unlike the hip's deep ball-and-socket joint, the shoulder is a shallow 'cup and saucer' joint, intrinsically very unstable. Its stability relies heavily on soft tissues like the labrum (a rubbery, suction-cup-like structure) and ligaments, rather than bony containment.

What is the difference between a subluxation and a dislocation?

A subluxation is an incomplete dislocation where the joint comes out but then easily pops back in. A full dislocation means the joint comes out and typically requires assistance to be put back into place.

When can shoulder pain indicate a neck problem?

If shoulder pain radiates down below the elbow and into the hand, it often suggests a neck origin, such as a pinched nerve in the lower cervical spine. Intrinsic shoulder issues typically do not cause pain below the elbow.

What is adhesive capsulitis or 'frozen shoulder'?

Adhesive capsulitis is a condition causing intense, spontaneous inflammation in the inner lining of the shoulder capsule, leading to significant stiffness and pain. While often self-limiting, severe cases may require physical therapy, cortisone injections, or even minor surgery to release the capsule.

What are the common causes and treatments for tennis elbow and golfer's elbow?

Lateral epicondylitis (tennis elbow) is often from activities like one-handed backhands, while medial epicondylitis (golfer's elbow) can result from over-hitting with pronators. Initial treatment involves rest, stretching, and NSAIDs. Cortisone injections are common for persistent pain.

When is Tommy John surgery indicated, and who typically needs it?

Tommy John surgery, which repairs the medial collateral ligament of the elbow, is almost exclusively for elite throwing athletes (e.g., baseball pitchers) who experience a rupture due to immense super-physiologic forces. It's not necessary nor recommended for non-athletes or to increase throwing velocity in healthy individuals.

What is the scaphoid bone and why are its fractures difficult to heal?

The scaphoid is a small carpal bone in the wrist, notoriously hard to heal due to its poor blood supply. It's mostly covered by cartilage, with limited blood vessels entering in a retrograde fashion. Fractures can easily disrupt this supply, leading to a high risk of non-union.

How is carpal tunnel syndrome diagnosed and what causes it?

Carpal tunnel syndrome is diagnosed by numbness and tingling in the thumb, index, middle, and half of the ring finger. It's caused by compression of the median nerve within the carpal tunnel, often due to swelling, inflammation (e.g., in pregnancy or rheumatoid arthritis), or repetitive pressure.

What is the significance of the ulnar nerve for hand function?

The ulnar nerve is crucial for grip strength and controls most of the intrinsic muscles of the hand, which allow for finger spreading, pulling, and precision movements. Damage to it can significantly weaken the hand's ability to perform fine motor tasks.

What are common overuse injuries in the hand and wrist?

Overuse can lead to tendonitis (inflammation of tendons) and tenosynovitis (inflammation of the tendon sheaths). These can cause pain, reduced mobility, and sometimes 'trigger finger' where a tendon catches due to nodular swelling within the pulley system.

What is basal thumb arthritis and how is it treated surgically?

Basal thumb arthritis affects the joint at the base of the thumb due to its inherent instability and complex range of motion over time. Surgical treatment often involves a reconstruction using the patient's own tissue, such as a tendon graft from the palmaris longus, to create a pseudoarthrosis.

What is the Musician Treatment Foundation?

Founded by Alton, the Musician Treatment Foundation provides free orthopedic care to uninsured and underinsured professional musicians. It addresses both common and unique injuries musicians face due to repetitive, asymmetric movements, helping them maintain their livelihood and mental well-being.

Key Moments

232 ‒ Shoulder, elbow, wrist, and hand: diagnosis, treatment, and surgery of the upper extremities

Peter Attia MD

Science & Technology7 min read274 min video

Nov 28, 2022|63,148 views|1,056|81

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TL;DR

Comprehensive guide to upper extremity injuries and treatments, from shoulder to hand, emphasizing diagnosis, and surgical and non-surgical care.

Key Insights

Upper extremity joints, especially the shoulder and thumb, prioritize mobility over intrinsic stability, making them prone to injury.

Orthopedic diagnosis relies heavily on a thorough history and physical exam, often outweighing MRI findings which can reveal asymptomatic degeneration.

Technological advancements like arthroscopy and biomechanically superior implants have revolutionized the treatment of shoulder and elbow injuries, allowing for minimally invasive repairs and improved outcomes.

Acute trauma, particularly in athletes, is common, but wear-and-tear conditions and genetic predispositions often lead to chronic issues like arthritis and tendinopathies.

For chronic conditions like frozen shoulder and epicondylitis, non-surgical interventions (PT, injections, rest) are often the first-line treatment, with surgery reserved for recalcitrant cases.

The hand and wrist, with their complex anatomy and innervation, present unique challenges, with the scaphoid bone being notoriously difficult to heal and nerve compressions like carpal tunnel syndrome being ubiquitous.

THE COMPLEXITY OF THE UPPER EXTREMITY

The upper extremities, encompassing the shoulder, elbow, wrist, and hand, are marvels of evolution, granting humans incredible mobility and dexterity. However, this comes at a price: reduced intrinsic stability in joints like the shoulder and the basal joint of the thumb. These cup-and-saucer-like joints, in contrast to the hip's true ball-and-socket, rely heavily on soft tissues—ligaments, tendons, and the labrum—for support. This delicate balance makes them highly susceptible to injury from both acute trauma and chronic wear, a fact often overlooked in general medicine due to its specialized nature.

EVOLUTION OF ORTHOPEDIC SURGERY

Orthopedic surgery, particularly for the upper extremities, has undergone a significant transformation since the mid-1990s. Early arthroscopic procedures were primitive, with most complex repairs, such as shoulder arthroplasty and labral repairs, performed through open incisions. The advent of sophisticated arthroscopic equipment and bioabsorbable or braided polyester anchors has enabled minimally invasive techniques. This evolution allows for smaller incisions, reduced muscle damage, faster recovery, and improved long-term outcomes, fundamentally changing the landscape of treatment for various joint pathologies, including rotator cuff and labral tears.

THE SHOULDER: ANATOMY AND COMMON INJURIES

The shoulder's glenoid fossa, likened to a golf ball on a very shallow tee, is inherently unstable. Key stabilizing structures include the labrum, a rubbery, calamari-like ring that deepens the socket and provides a suction effect, and the four rotator cuff muscles (supraspinatus, subscapularis, infraspinatus, and teres minor), which dynamically stabilize the joint. Common injuries include rotator cuff tears (degenerative or traumatic), labral tears (like SLAP tears, often seen in overhead athletes), and dislocations/subluxations. The biceps tendon, anchoring to the superior labrum, is another frequent pain generator.

THE AC JOINT AND IMPINGEMENT

Beyond the main glenohumeral joint, the acromioclavicular (AC) joint, where the clavicle meets the acromion (the bony roof of the shoulder), is also a frequent site of injury and pain. AC joint separations, common in falls, range from mild sprains (Type 1) to complete dislocations (Type 3 or higher). Impingement syndrome occurs when the rotator cuff tendons and bursa rub against a down-sloping acromion or bone spurs, leading to inflammation (bursitis) and potential fraying or tearing of the cuff. Genetic predisposition to certain acromion shapes (Type 3) can increase susceptibility to impingement in active individuals.

FROZEN SHOULDER AND REFERRED PAIN

Adhesive capsulitis, commonly known as frozen shoulder, is a distinct condition characterized by intense inflammation and thickening of the joint capsule, leading to severe stiffness and pain. While often self-limiting, it can be debilitating and, in a subset of cases, may require surgical release. Importantly, shoulder pain can also be referred from the cervical spine, often presenting with symptoms radiating below the elbow, distinguishing it from intrinsic shoulder pathology. A thorough history and physical exam are crucial to differentiate these sources of pain, avoiding unnecessary shoulder interventions.

THE ART OF DIAGNOSIS: BEYOND THE MRI

A comprehensive orthopedic diagnosis prioritizes a detailed patient history and a meticulous physical examination, often achieving 95% accuracy before imaging. The history includes mechanism of injury, activity patterns, and specific pain triggers. The physical exam involves palpation for tenderness and asymmetry, evaluation of active and passive range of motion, and specific strength testing to isolate individual muscle-tendon units (e.g., rotator cuff, biceps). Provocative maneuvers further pinpoint pathologies like labral tears (e.g., active compression test) and impingement. MRIs primarily serve to corroborate clinical findings rather than dictate treatment, given the prevalence of asymptomatic findings (e.g., rotator cuff tears in individuals over 60).

SURGICAL CONSIDERATIONS: WHEN TO OPERATE

The decision to operate is nuanced and guided by the patient's symptoms, functional impairment, biological age, and a discussion of risks versus benefits, rather than solely by imaging findings. For instance, a 97-year-old active individual with debilitating arthritis may be a candidate for shoulder replacement, while a younger person with mild labral tears often benefits from conservative management. Under anesthesia, a dynamic exam can reveal instability not apparent during conscious examination due to muscle guarding. Capsular tightening (capsulorrhaphy) may be performed concurrently with labral repair if significant laxity is present.

SHOULDER ARTHROPLASTY: A QUALITY-OF-LIFE ENHANCER

Total shoulder replacement is indicated for severe, symptomatic arthritis where cartilage is completely worn down, causing pain and functional limitation. Unlike hip or knee replacements, which restore basic mobility, shoulder replacements (humeral head with a polyethylene glenoid component) primarily enhance quality of life, allowing patients to resume activities like swimming, golf, and light weights. Recovery is generally excellent, with most patients able to perform daily tasks and recreational activities, significantly improving their functional independence. The procedure uses durable Cobalt chromium alloys and ultra-high molecular weight polyethylene, similar to other joint replacements.

THE ELBOW: STABILITY AND COMMON TENDINOPATHIES

The elbow joint, formed by the humerus, ulna, and radius, is intrinsically more stable than the shoulder due to its complex undulating surfaces. However, this rigidity makes it less forgiving to injury, with even subtle fractures potentially leading to rapid joint destruction. Common overuse injuries include lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow), caused by repetitive stress and often associated with micro-tears in the forearm extensor or flexor tendons. Distal biceps tendon ruptures, often seen in active middle-aged individuals, cause a significant loss of forearm supination strength.

TOMMY JOHN SURGERY AND TRICEPS INJURIES

The ulnar collateral ligament (UCL), infamously known as the Tommy John ligament, is critical for high-velocity throwing athletes. Its rupture, often due to supra-physiologic forces, can end a pitcher's career if not surgically reconstructed. Tommy John surgery (UCL reconstruction) has revolutionized professional baseball, allowing many athletes to return stronger. Conversely, the triceps tendon, attaching to the olecranon, can rupture from eccentric loading, such as falling with an outstretched arm. Given the triceps' role in pushing and extending, these ruptures are highly disabling and almost always require surgical repair.

HAND AND WRIST: THE FRONTIER OF INTERACTION

The hand and wrist represent extreme complexity, vital for interaction with the world and cognitive function, with over 60% of higher cortical neurons dedicated to their control. Advances in microvascular techniques have revolutionized reconstructive surgery, making previously unmanageable nerve and blood vessel injuries treatable. Recent breakthroughs include complete hand transplantation for bilateral amputees. Common injuries include distal radius fractures and scaphoid fractures—the latter being notoriously slow to heal due to its poor blood supply and often initially missed on X-rays. Surgical intervention for scaphoid fractures (e.g., Herbert screw) can expedite healing and recovery, particularly for athletes.

NERVE COMPRESSION AND TENDINOPATHIES IN THE HAND

Carpal tunnel syndrome, a ubiquitous condition, involves compression of the median nerve within the carpal tunnel, caused by the transverse carpal ligament and aggravated by swelling or repetitive wrist flexion. Symptoms typically include numbness and tingling in the thumb, index, middle, and half of the ring finger. While typing alone rarely causes carpal tunnel syndrome, it can exacerbate existing conditions. The ulnar nerve supplies most of the hand's intrinsic muscles, essential for fine motor control. Chronic overuse can also lead to tenosynovitis (inflammation of tendon sheaths), causing pain, stiffness, and sometimes tendon locking, often treatable with conservative measures or minor surgery.

Mentioned in This Episode

●Products

●Tools

●Companies

●Organizations

●Books

●Concepts

●People Referenced

Common Questions

Fellowships have become almost mandatory in orthopedic surgery, allowing surgeons to develop a special interest and sub-specialize. This is due to the vast knowledge explosion and the need for specialized skills when applying for positions in groups or hospitals.

Topics

Neuroscience & the Brain Human Performance Sports Medicine Orthopedic Surgery Musculoskeletal Health Medicine & Clinical Shoulder Injuries Elbow Injuries Hand And Wrist Injuries Surgical Intervention Nerve Compression Musicians' Health

Mentioned in this video

Organizations

Tulane University

Alton's medical school, which had a large orthopedic residency program.

IRS

The Musician Treatment Foundation obtained its 501(c)(3) status from the IRS in 2017.

Physicians for Musicians (P4M) Network

A new network founded by Alton, expanding the Musician Treatment Foundation's reach by recruiting over 60 surgeons nationwide to provide care for musicians.

Roosevelt Hospital

Where Alton completed his hand fellowship in New York.

FDA

Mentioned in the context of device approval during the early days of arthroscopic surgery, with limited involvement for humanitarian devices.

Columbia University

Where Alton completed his shoulder fellowship in New York.

Metropolitan Opera

Another prominent classical music organization whose orchestra musicians Alton has provided care for.

New York Philharmonic

One of the classical music organizations whose musicians Alton has treated and consulted with.

Health Alliance for Austin Musicians

A local organization in Austin that supports musicians' health, which the Musician Treatment Foundation now collaborates with.

NFL

Mentioned in the context of AC joint separations, where a study showed many type III injuries in NFL athletes did not require surgical treatment.

Musician Treatment Foundation

A foundation founded by Alton six years prior to the recording, providing free orthopedic care to uninsured and underinsured professional musicians.

WashU

Washington University, where a natural history study on asymptomatic rotator cuff tears was conducted.

Media

Popeye

Used as an analogy for the muscle deformity that occurs after a biceps rupture, where the muscle balls up.

Vitruvian Man

Leonardo da Vinci's drawing, referenced when discussing the elbow's carrying angle in human anatomy.

Drugs & Medications

prednisone

A steroid that can be used orally to manage neck and shoulder pain, especially when a neck component is suspected.

Nonsteroidal anti-inflammatory drugs

Used to control inflammation in conditions like adhesive capsulitis and tendonitis.

Cortisone

A type of steroid injected to reduce inflammation in various joint conditions like frozen shoulder, tennis elbow, and golfer's elbow, providing dramatic pain relief.

Books

Cope's Early Diagnosis of the Acute Abdomen

A classic medical text on diagnosing appendicitis clinically, used to illustrate the importance of clinical acumen over sole reliance on imaging.

The Comfort Crisis

A book by Michael Easter, which discusses the human capacity for carrying heavy loads and introduced rucking to many, including Alton.

Concepts

polyethylene

Ultra high molecular weight polyethylene used for the glenoid cup in total shoulder replacements, known for its durability.

Orthopedics

A medical specialty focused on the musculoskeletal system, often highly specialized despite its broad nature.

parsonage-turner syndrome

Also known as brachial neuritis, an uncommon condition caused by inflammation of the brachial plexus, leading to acute pain, weakness, and numbness in the upper limb.

MacPherson strut

An analogy used to describe the function of the AC joint as a stabilizer bar, preventing the shoulders from collapsing inward.

Rucking

A physical activity involving walking with a weighted backpack, recommended by Peter Attia, which Alton found to be a game-changer for his body and strength.

Nursemaid's elbow

A common injury in children where the radial head subluxes at the elbow, often caused by a parent pulling a child's arm.

Medicare

Used as a benchmark for the significantly reduced costs offered by the Musician Treatment Foundation's surgery center.

Companies

IBM

Mentioned in a class action lawsuit regarding carpal tunnel syndrome, where it was not proven that typing directly caused the condition.

Locations

Broadway

The New York theater district, where Alton has treated musicians from diverse genres involved in various shows.

People

Jennifer Jackson

A singer-songwriter from Austin and the Musician Treatment Foundation's first surgical patient, treated for bilateral full-thickness rotator cuff tears.

John Leventhal

Musician participating in an upcoming Musician Treatment Foundation concert.

Tommy John

The medial collateral ligament (ulnar collateral ligament) of the elbow, frequently torn in high-level throwing athletes and requiring reconstructive surgery.

J. William Littler

A famous hand surgeon who contributed to the development of microvascular techniques for hand injuries, drawing from war experiences.

Diana Krall

Musician and co-founder of the Musician Treatment Foundation, serving as a full board member.

Quinn Ewers

UT quarterback who sustained a sternoclavicular joint injury in the Alabama game.

Rosanne Cash

Musician participating in an upcoming Musician Treatment Foundation concert.

Jason Isbell

Musician participating in an upcoming Musician Treatment Foundation concert.

Nolan Ryan

Legendary baseball pitcher, referred to when discussing the natural limits of throwing velocity vs. surgical enhancement.

Michael Easter

Author of 'The Comfort Crisis', known for advocating rucking and discussing the human capacity to carry things.

Elvis Costello

Musician and co-founder of the Musician Treatment Foundation. He performed the first fundraising concert.

John Elway

Former NFL quarterback who experienced shoulder pain and retirement thoughts, but found relief after a biceps rupture and then won two Super Bowls.

Ken Yamaguchi

A friend of Alton and lead on a study from WashU on the natural history of asymptomatic rotator cuff tears.

Steve Snyder

A fellow from Northern California who categorized and identified SLAP tears as clinically relevant entities, especially for younger athletes.

Products

Herbert screw

An ingenious screw with two sets of threads of different pitches, designed to compress scaphoid bone fragments together, revolutionizing treatment for scaphoid fractures.

Platelet-Rich Plasma

A treatment involving injecting a patient's own plasma, rich in growth factors, into an injured area, but current clinical data for rotator cuff tears and tennis elbow are not convincing.

Cobalt chromium alloy

The metal used for humeral head resurfacing and the head component in total shoulder replacements, similar to hip implants.