I'm Dr.

Ryan Harden, faculty member from the department of family medicine and biobehavioral health at the University of Minnesota Medical School Duth campus and family medicine physician at the Gateway Family Health Clinic in Moose Lake.

I am your host for our episode tonight on care and treatment of the upper extremities.

The success of this program is very dependent on you, the viewer.

So, please call in your questions or send them in to our email address, askpbsnorth.org.

Our panelists this evening include Dr.

Dylan Wyatt from Aspirus St.

Luke's Emergency Medicine and Dr.

Dr.

Bradley Kzel, an orthopedic surgeon from Essentia Health Duth.

Our UMD medical student phone volunteers tonight are Gunnar Carly from Howley, Minnesota, Nate Karsski from Jordan, Minnesota, and Kale Hendris from Duth, Minnesota.

And now on to tonight's program on cancer um the upper extremity.

Well, welcome doctors.

I've been really looking forward to this the first the first show of this year after the holiday break and I'm pretty excited to see what kind of questions we're going to get from our viewers tonight.

Uh first of all, if Dr.

Kusel, if you'd like to tell us a little bit about your practice.

Sure.

Yeah, my name is Brad Kusel and I'm a upper extremity surgeon.

So that means I take care of of orthopedic issues, you know, from basically from the shoulder to the fingertips.

Uh and I've been at Essentia Health here in Duth for the last 14 years.

All right.

Wonderful.

And Dr.

Wyatt, if you could talk a little bit about your practice.

Absolutely.

Uh, I'm Dr.

Dylan Wyatt.

I'm an emergency medicine physician.

Um, which means that I take care of this stuff right when it happens before it gets to a surgeon.

Um, trying to, uh, you know, set limbs, etc.

when it happens.

And I've been at St.

Luke's, Spar St.

Luke's for about five years now.

Okay.

Wonderful.

Well, I collected a couple questions from my patients this week in anticipation of tonight's show.

So, uh, and this is one that I'm really interested in because, um, I like preventive medicine, but one of my patients asked, "How can I prevent from getting a rotator cuff problem?"

That's a it's a really good question.

Uh, there are some things that you can do to to prevent rotator cuff injuries.

Some of them just are related to genetics, how our bones are shaped, and and things like that.

So the things we can do especially up here in in Duth wear good shoes in the winter time have good traction.

We see a lot of injuries and when people fall and especially when they fall and hit their elbow it's very common for them to have a rotator cuff injury.

Uh so being really smart that way when you're lifting heavier objects kind of keep them close to your body and when they're further out that's more of a a position where you're prone to injury.

And then I I think um you know the the kind of the key things are there's a lot of things we can do with our diet like eating healthy foods.

You know if there's a lot of ingredients on the back of the package that you can't pronounce it's probably not that good for and we are what we eat.

And so eating healthy foods, regular stretching, exercise, drinking a lot of water, avoiding a lot of processed sugars, things like that.

All those things I think go into our overall health and that ultimately trickles down to the rotator cuff.

All right.

Thanks.

And uh another one of my patients was wondering, Dr.

Wyatt, if they need to have surgery for their trigger finger.

Oh boy, that's that's a great question for an upper extremity surgeon.

Yeah, I think it's all about functionality, right?

It comes down to if it's impeding your ability to function and do your day-to-day activities, right?

You know, when people have trigger finger, a lot of times we'll try a lot of things before surgery.

We'll try things like braces on on this joint to keep the finger straight at night.

Um, people will do deep tissue massage.

Sometimes we'll use anti-inflammatories like ibuprofen or topicals and we'll do things like cortisone shots.

And if that's if it's still bothering them a lot or if somebody's had multiple trigger fingers, there's a really kind of a it's a pretty small surgery that we can do under local.

It usually takes less than 10 minutes to do that works really well.

And so, but we usually try to do all those things before, you know, we we think about surgery.

Okay.

Excellent.

And Dr.

Wyatt, another patient was wondering why their little finger keeps falling asleep.

Why would that be?

That could be a lot of different reasons.

Um, you know, when we think of a finger falling asleep, that could be an interruption in blood flow or it could be compression on a nerve with the nerve sending the signal back or the blood flow that leads to, you know, the actual feeding of that nerve so it can send the signals back.

Um, the first thing I would say is think about the way that they are moving for the person to think about the way they're moving dayto-day, right?

How are they using their hands?

Are they resting their hands in a certain way in their place of work if they work with their hands?

Um, I would also say if they have any history of heart disease, stroke, high cholesterol, that's something you're going to want to bring up with your primary care team the next time you see them because that could be a warning sign for vascular disease.

Okay?

And then think about what kind of clothing you're wearing.

Sometimes if you have really tight clothing or if you're, you know, in certain positions for long periods of time during the day, it can cause compression of the nerves and blood vessels that can lead to these symptoms.

So, lots of things probably something that they should get checked out with their doctor.

I think it's a good idea.

Okay.

Um, Dr.

Kzel, one of my patients was wondering he needs to have a joint replacement because of arthritis and he was asking me what is the difference between a reverse shoulder and a regular joint replacement.

Yeah.

So, there uh usually when I'm talking with patients in clinic about what we call like a standard total shoulder arthroplasty and a reverse total shoulder arthoplasty, I'll use pictures to describe because I think it makes it a lot easier.

But reverse shoulder replacements were initially developed for patients with massive irreparable rotator cuff tears, not necessarily arthritis, although some of those people get arthritis because of those rotator cuff tears.

And then standard replacements are done for patients with kind of regular osteoarthritis and but an intact rotator cuff.

So with the reverse, you know, when we do any kind of joint replacement, whether it's a hip or a knee or shoulder, we're kind of resurfacing both sides of the joint, kind of putting a new metal ball and a new socket on the shoulder.

And in the rever in the case of the reverse shoulder replacement, we actually put the ball where the socket used to be, and then the sockets where the ball used to be.

And that kind of and then this big muscle here, the deltoid muscle is what kind of takes over and that's what raises the arm or helps people raise their arm.

And that's why it's worked well for patients with rotator cuff or like chronic rotator cuff issues.

The interesting thing though now is that I've been in practice for 14 years and the designs of reverse shoulder replacements have evolved over time and we're now in the third or fourth generation and we're seeing a lot more reverses done even for arthritis because they take away some of the potential risks of a standard replacement.

So, it's a really it's a good it's a good operation for arthritis and for rotator cuff pathology.

Well, thank you for that answer.

Um, Dr.

Wyatt, this is a question that comes up in my practice a lot.

Um, how does a patient know if they injured their rotator cuff or if they actually tore their rotator cuff?

My understanding is mostly it's time.

So, an injury and a tear, you know, you're thinking did you strain or pull the muscle, harm it?

Is it inflamed or is it torn?

so that there's more permanent damage done.

Um, really only time is going to tell you that potentially MRIs could to my understanding if you really want to dig down into it.

But from an emergency room perspective, if I see someone that has an exam concerning for a rotator cuff or injury, whether it's a tear, whether it's a strain, we're going to recommend more conservative measures first, resting it, icing it, gentle stretching to maintain range of motion without overdoing it, limitation and lifting, and doing a lot of careful work with their biomechanics and how they're lifting and turning things like you were talking about earlier because that can help prevent additional reinjury or worsening of that injury.

Okay.

And and a patient from Sandstone was wondering why their shoulder hurts when they sleep on their right side.

Is it is it the shoulder that they're laying on or the other shoulder?

Why does their right shoulder hurt when they lay on their right side?

Yeah, I think that's a really good question.

We don't always know the answer.

Uh you know, if I I had I get to look in shoulders all the time when I do shoulder arthoscopy.

So, we get to look inside and see what's going on.

And there's a lot of inflammation in there.

And I think sometimes it could be related to that.

Um, but you know, and there are patients who have the other shoulder hurts and their shoulder that's injured feels better when it's on the kind of the side that's kind of the lower side that's on the mattress because it's kind of splined or stabilized.

And so, you know, every, you know, patients are all different and and people experience things differently, but you do see certain trends with certain injuries.

Okay.

Excellent.

Thanks.

Um, Dr.

Wyatt, this is one that I think might show up in the ER a lot.

What is costchondritis?

A caller from Hermantown is wondering this one.

Excellent question.

So, breaking it down, it it's inflammation of cartilagages in the ribs, right?

And that can be very it's a condition we see often as uh it manifests usually as chest pain or trouble with pain with breathing, trouble with breathing.

All very concerning symptoms that we often times want to get checked out.

But at the end, if the heart is okay, if the lungs are okay, if points on those ribs are tender, that may be the problem.

And that's more of a rest, take it easy, stretch kind of thing.

So, oftentimes on our end, it comes across as a good thing.

Hey, these are your ribs, this isn't your heart, this isn't your lungs, even though it can in the long term cause some really uh fairly decent discomfort um for folks.

Okay.

Excellent.

So, that's one of the one of the types of chest pain that we're not as worried about, correct?

Yes.

Yeah.

Muscularkeeletal chest pain.

It's kind of falls in that category.

Um Dr.

Kzel, when patients are getting ready to have surgery on their shoulder, they a lot of times they'll ask me why they are required to go to physical therapy before or after the surgery.

Why is that?

There's a lot of good reasons to do therapy.

And oftentimes we'll recommend therapy.

will try to do non-surgical things before surgery because there are patients out there who can even have complete tears and have pretty good strength and not have a lot of pain and and so we always want to try some therapy to see if we can get a patient there.

Um if a patient still has pain despite therapy, they've learned some new exercises and they've learned some you can almost think of it as like a prehab.

When somebody has an ACL injury, we don't do surgery right away.

We want to get their muscles strong in their leg beforehand.

So somebody can do some therapy before surgery.

It's like a tuneup.

It gets them ready so that they can have a successful recovery.

Pragmatically, we deal in a world where there's things called prior authorization for surgeries.

And there's a lot of surgeries that aren't authorized.

They're simply not authorized unless you've tried some physical therapy.

And and so I'll talk with patients about that, too, because I hate for somebody to be scheduled for surgery and changed their whole life around.

you know, they're they've made arrangements with their job and their family and and then two weeks before surgery, the the surgery's canceled because of an insurance issue.

And so, we try to kind of be on the the fronts, you know, be plan for that, you know, and help patients.

But again, I even with that all that said, I think there's a lot of value in therapy before surgery for the other reasons that I mentioned.

And there's a lot of joint upper extremity problems that can pre be treated with just therapy, just physical therapy.

Oh yeah.

Exactly.

Yeah.

Yeah.

I mean I orthopedic surgeons we always I I loved it when you said earlier that you know somebody's got a shoulder injury.

You kind of rest it for a little while and then you start moving it because a lot of people are afraid and rightly so.

People are afraid to start moving their arm when they've had an injury.

they think they might injure it more, but really motion is there's this old orthopedic saying, motion is lotion, you know.

So, you know, getting that joint, getting the shoulder moving.

I'll see people and I know that if they just start moving it a little bit more, climbing up the wall or, you know, doing different things like that that their shoulder will start to feel better and so there's a lot of value in therapy and movement.

Okay.

Excellent.

Dr.

Wyatt a caller from Cloquet is wondering what is the best treatment for tennis elbow.

So maybe first talk about a little bit little bit about what tennis elbow is and then what would the best treatment for that be?

So a tennis elbow and this can generalize to a lot of different upper extremity ligamentous and um muscular strains.

It's an overuse injury from repeated swinging with the same ligaments, same muscles being put under repeated stress.

That can be, you know, you can get skiers, you can get all kinds of injuries from different sports, activities that stress a certain ligament.

Compression is going to be really key.

Using wraps is really helpful because it moves that point of stress to a different part of the tendon of the ligament of the muscle.

So, you're allowing that injured portion to rest.

Lots of ice, reduction in the activity that stresses that part.

So, you know, stop playing tennis for a little while.

Um, anti-inflammatories like ibuprofen, Tylenol can be helpful as well.

And then if that doesn't help then sometimes physical therapy may be necessary on top of that or if it continues referral to even a potential higher level option.

Yeah, there are some there are surgeries that can be done but with tennis elbow I really like to try everything possible before end because it's not an injury that if you don't treat it's going to end up being a a bigger problem later on.

One of the best things you can do is a stretch where you just put your wrist down, rotate out and then just stretch like this.

And you know, it's the number one thing you can do, but a lot of people haven't tried it yet, and it hurts a little bit, but it's it's okay.

And oftentimes it'll help relieve symptoms with with tennis elbow.

Okay, excellent.

Thanks for that answer.

Um, a caller from Proctor is wondering when should they use heat or cold for an injury?

This is something interesting because for a long time I at least learned back when I was uh you know amateur athlete in school.

Well, you got to use cold for cooling off the joint and then heat whenever you're going to use it.

Essentially what the data has now shown is if it feels good, do it.

You know, you want to do some time on, some time off, 15 minutes on, 15 minutes off for a few cycles to give, you know, t the tissues time to rest between the cold cycles.

um or with heat, too.

But if it feels good to that joint, you should do it.

It's not going to cause damage.

As long as you're being careful with the application of it, and if it helps it feel better, and that helps you be more functional, that's that's the goal.

So, really, it depends whichever one works.

Yeah.

Listen to your body.

All right.

Excellent.

Thank you.

Um I'll put this one up for both of you to answer.

Uh what a caller from Duth is wondering, and we touched on this earlier, but since somebody was asking about this, I think we'll we'll talk about a little bit more.

What exercises can I do for a rotator cuff injury?

Yeah, I think the the when somebody has an injury, the kind of the first thing you focus on is that motion.

And so stretching.

And I always tell people if it's within a normal range of motion, it's okay.

Even if it hurts, you're not going to tear something more.

Like if you're walking up a wall or you're sliding your arm on a table, it's very safe to do that.

Or the other rotations are like external rotation, internal rotation behind the back.

Those are all very safe things to do.

So, you really want to get those things kind of normalized.

And then we want to start focusing on some strengthening of not only the rotator cuff muscles, but all the muscles that are around the shoulder.

There's many muscles around the shoulder and the shoulder blade.

And so, oftentimes that's where therapy comes into play or working with an athletic trainer where you can work with some band training for external rotation, strength, intern rotation, strength, bringing those shoulder blades together, strengthening the muscles in between the two scapula bones.

And then strengthening your core.

I always tell folks, you know, your shoulder is kind of a the core is the foundational block and the shoulder's on top of that.

So if your core is good, then your shoulders, you know, you got to have a good core to have a good shoulder.

And so um I think that's kind of how I typically think about it.

Motion first and then strengthening after that.

Okay, wonderful.

Um another caller from Duth, Dr.

Wyatt is wondering, "If I have arthritis in my shoulders, does that mean I'm going to ultimately need surgery?"

Not necessarily.

It's all about your function and the amount of discomfort you're experiencing.

Um, especially up here in the Northland, I know you've met them, people that have, frankly, horrible arthritis, very painful symptoms, but they go, "Nope, I don't want to do surgery.

I can do I can garden.

I can cook.

I can do what I want to do in my dayto-day, and I'm fine."

For some people, the amount of discomfort they're experiencing or the activities they need to do can't be supported by their level of arthritis, and so they will need additional intervention.

It's entirely up to the individual.

At some points, there may be recommendations from their physicians.

Hey, this looks like it's really hurting you.

It's impairing your function.

We'd recommend that, but it's up to the individual depending on how their symptoms are.

Yeah.

and how whether they're managing it appropriately, doing their exercises and taking over the counter medicines maybe might those conservative therapies we talked about.

Okay.

Thank you.

Um Dr.

Kzel, I've seen this in my practice a couple times where patients have had carpal tunnel surgery but then years later their symptoms return.

What do we do about that?

Yeah.

So when that happens usually what I like to I I I take kind of a multiacet approach.

Okay, obviously we're going to see them.

We're going to get a history, do an examination.

Uh but really, if they had a prior EMG before their the prior surgery, we'll want to get another EMG to see if there's been a change because often times when people have carpal tunnel, the EMG will improve.

The EMG is kind of this nerve test that assesses how healthy or unhealthy the nerves are and if they are compressed, which location, you know, it could be the neck, shoulder region, elbow or at the carpal tunnel.

So, we want to do that.

Sometimes that one of the great things at Essential Health is we have this really wonderful MSK ultrasound program.

And so, that's another tool.

I know they use ultrasound a lot in the ERs as well.

Another tool that we can use to look at the carpal tunnel and see if the nerve is compressed.

And it doesn't happen often.

Uh but there are people out there that I've taken care of that have had recurrent carpal tunnel and when you do the surgery, yep, there's a big bar of scar tissue that's pinching the nerve.

and why it developed after 15 years, who knows?

But that's one of the the mysteries, but um that's the approach that I'll take.

Okay.

Wonderful.

Um Dr.

Wyatt, a caller from Hermantown is wondering arthritis verse pseudo gout.

How do you differentiate between the two?

Oh man, we could go on a whole thing about this because technically pseudo gout is a form of arthritis.

But when we talk about arthritis colloquially, we're talking about osteoarthritis or a wearing down of the joint surface over time from aging and overuse.

That's kind of colloquially how we we use the term arthritis.

Whereas pseudo gout and gout are both accumulations of crystals within the joint space itself that are almost like little knives that rub against each other.

It hurts.

It's very uncomfortable.

there's swelling and um that's managed in a very different way than we would manage the osteoarthritis or the overuse arthritis uh that you get over time in the long term.

Okay.

Wonderful.

Um I can't tell where this patient's calling from but or where this caller is calling from but and I'll put this out to both of you.

This I think this is a difficult question.

Patient has a degenerative disc disease and cervical herniated discs.

she doesn't want to have surgery.

What are her other options?

That's tough.

Um because that that gets into that function stuff, right?

And it's complicated as well because it would need a whole another specialty in neurosurgery to get involved because they they deal with the discs and um and the spine.

But if the person feels functional, if they are able to maintain doing their day-to-day activities, and if they are able to manage their pain, I think it's potentially reasonable if they continue to talk with their physician team to hold off.

But the challenge with discs in the neck is that those things can be unstable and can potentially cause issues at a moment's notice depending on how bad they are.

So it would really be important to talk to their neurosurgery team as well and to kind of talk with the whole team about this because there's strengthening they can do, there's symptom management, but there's only so much that that can go into that at some point.

Okay.

So sometimes that can be very difficult to manage over time.

Yeah.

Yeah.

Kind of a month by month, day by day thing.

Um I'm going to ask you this question, Dr.

Wyatt.

This is a kind of a acute care question.

Um, if my shoulder's dislocated, how is it treated and how do I prevent it from happening again?

That is a great question.

Um, the first and most important part is to try and get to an ER as soon as possible so we can fix it.

The longer it is out, the more damage can be done to the nerves, to the joint itself, to the the joint surfaces and the bone.

We will usually either sedate or inject the joint to numb it up and then we'll pop it back into place, put the ball back into the socket where it belongs.

Preventing in the future is more challenging because depending on what damage was done from the first dislocation, it can become a recurring thing or with good strengthening and physical therapy, we can try and avoid that and some activity modification that that person's football career might not be able to continue.

I I like how you said we'll just pop it back into place.

I've been told before that the way that us ER folks address that sometimes people like, "Hang on a second.

You just pop it into place."

Yeah, it's kind of routine for us.

It's actually one of the more fun procedures we do because there's a satisfying conclusion to it, right?

There's a big clunk, the person feels better and they can go home feeling better.

So, that's that's kind of nice.

Well, great.

Thank you.

We don't want anyone to dislocate their shoulders, but we're happy to take care of it when it happens.

And Dr.

Kusel.

Um, a a patient from Superior is wondering how long after carpal tunnel surgery should they expect 100% recovery.

It really depends on kind of the severity of their carpal tunnel going in.

And so, and this is something that I talk with patients.

I spend a lot of time talking about if they have severe carpal tunnel on their EMG, there's some permanent damage to the nerve and they will never have full recovery.

oftentime one of the main symptoms that somebody with carpal tunnel will have is they wake up many times at night with numbness in their hand or pain and the surgery will help with that and it may help with the numbness but it doesn't always go away when it's severe on the EMG prior so it's really important to have that conversation with people beforehand u but there are studies that show that in general patients with carpal tunnel they look at a lot of different variables we have all these outcome measures and things that we do people get better up to about nine months and then they start to plateau after that.

And so I'll tell patients, yeah, I mean, you're going to keep getting better up until about 9 months or maybe even a year out, but then that when you're there, that's how it's going to be.

Okay.

Wonderful.

Thank you.

Um, Dr.

Wyatt, this is kind of a follow-up question to what we were talking about with the shoulder dislocation.

So, a caller from Superior is wondering, they dislocated their shoulder a few months back and they struggle to raise their arm.

What should they do?

Oh, boy.

That's and I'm assuming that the person had it relocated.

Um the challenge is sometimes even if that person had the dislocation, immediately went in to be seen, got it reduced properly, sometimes the act of dislocating itself can damage nerves that are important in the function of moving the shoulder.

It could also be a bony problem um where there's been some actual damage to either the socket or the ball joint.

Um, but my first worry there would be that there was some nerve damage that can be compensated for with good physical therapy.

Strengthening the muscles around there, but I would definitely talk to their doctor about that because it's a it can be looked at and potentially therapy can help, but it should be looked at.

And we'll just sneak in one more question and I'll put this question out to both of you.

A patient has wrist pain after a weightlifting injury with a negative X-ray.

What should they do next?

First thing I would do is give it some time.

You know, the body heals and the body knows what it wants to do to heal it.

It just takes a while and it's not as fast as people like, but I would give it, you know, weeks and if not months and you want to see it gradually getting better over time.

uh and do those things.

Work on the range of motion.

Make sure that you're you're keeping that wrist motion the, you know, normal and uh and some light strengthening.

If it's not getting better, then you want to see somebody.

Uh maybe you get another set of X-rays.

There could always sometimes there are injuries that don't show up right away.

Sure.

And they can show up a week or two later.

Um like a scapeoid, like a wristbone fracture.

Um, and sometimes that other that that the the person you're seeing if you're having persistent pain and it's been months would get an MRI.

Well, I want to say thank you to Dr.

Kel and Dr.

Wyatt.

I certainly learned a lot.

I hope our viewers did.

Uh, please join us next week on Doctors on Call where Dr.

Chris Akoy will be joined by regional experts for a panel discussion about care and treatment of the lower extremities, hips, knees, and ankles, joint replacement options, and prevention with a panel of experts from around the region.

And if you're looking for more tips, tricks, and conversation around health and wellness in the Northland, make sure to check out Northern Balance on the PBS North YouTube channel.

Thank you for watching, for joining us tonight for season 44, episode number one in this year.

And good night.