There are four different muscles that stabilize the ball and socket that make up the shoulder joint. These muscles are responsible for arm movement and shoulder stability. Through repeated heavy lifting, incorrect posture the tendons which attach muscles to bone may injure and tear. The muscles forming the part of the rotator cuff are Supraspinatus, Infraspinatus, Teres minor as well as Subscapularis, although the most common tear is of the tendon of Supraspinatus muscle. Torn Rotator Cuff Signs and symptoms include: • Pain and weakness with overhead movements • Pain with putting on and taking off clothes • Pain with reaching behind the back when showering • Pain with lying on the painful shoulder • Difficulty performing physical activity or even job duties It’s not uncommon for people with a rotator cuff tear to feel the following: • Increased pain in the shoulder with lifting or during overhead activities. • Inability to fully lift arm due to weakness of the shoulder muscles. • Pain in the shoulder at night, keeping them from sleeping • Pinching, catching, or popping sounds in the shoulder with movement • Restricted range of motion, especially with reaching behind the back or overhead Though most often rotator cuff tears are of traumatic origin, degenerative tears with increasing age are equally common and should be considered for repair too in symptomatic patients. Rotator cuff tendon tears are ultimately confirmed through Magnetic Resonance Imaging (MRI). A rotator cuff repair is a surgery to restore the muscle tendon attachment to the humeral head (the ball of the ball and socket shoulder joint). It is most often done today through an arthroscopic technique – small incisions around the shoulder. PRE-OPERATIVE STEPS Every effort is made to assess the patient prior to surgery in order to ensure safety of the patient for the elective procedure. 1. After admission, routine blood work-up will be done prior to surgery. Depending on the age of the patient and other premorbid conditions, other investigations such as Echocardiography may be performed in elderly patients. 2. All the investigations prior to surgery are performed in order to ensure that the surgical procedure can be safely tolerated by the patient, since shoulder arthroscopy is an elective procedure. If any risk is involved, the patient/ attendants will be informed so. 3. Blood transfusion though rarely required, may be done depending on the reports. 4. X-rays and MRI will be done ideally in order to guide the surgical plan and the prognosis. 5. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. INTRA OPERATIVE STEPS 1. After anesthesia induction and patient positioning your surgeon will make two small incisions in the front and one small incision each in the back and the side of the shoulder joint. 2. The surgery is performed using a small fiberoptic camera (an arthroscope) and other small instruments inserted through the incisions. 3. The fatty tissue which is leading to symptoms of bursitis is removed along with a burr thinning of undersurface of the acromion bone is performed which is known to cause rotator cuff tears. 4. The remaining portion of the torn rotator cuff muscle tendon is mobilized after clear visualization through the arthroscope. 5. After mobilization, suture anchors are inserted into the underlying humerus bone. 6. The tendons are fixed to suture anchors with the help of a device known as Firstpass. 7. Once sufficient hold is obtained in the tendons, knots are applied in order to fix the tendon into the original insertion site on the bone. 8. Once the rotator cuff tendons are firmly in place, the incisions are then closed with small bandages and the surgery is complete. POST OPERATIVE STEPS After surgery, patients will take home a sling used to protect the arm and the newly repaired tendons. Patients need to wear the sling for the first 6 weeks even during sleep. Patients may take the sling off when bathing or performing physical therapy exercises. DON’Ts for the first 6 weeks: • Don’t lift your surgical arm overhead without help • Don’t reach behind your back • Don’t pick up any heavy objects with the surgical arm • Don’t push or pull any objects with the surgical arm • Don’t perform any chores or physical labor requiring the use of your surgical arm Pain Management after Shoulder Surgery Most patients with rotator cuff repair will have some level physical discomfort which is normal. The pain could be sharp when first attempting to move the arm. Most surgeons will prescribe medications which should be taken to reduce pain but the patient should continue with the rehabilitation program. Ice is helpful to reduce inflammation and improve pain in the initial recovery process. Place an ice pack or cold compress over the shoulder for up to 20 minutes several times a day especially when recovering the first few weeks. Some pain and inflammation are normal for routine healing. However, some things may be concerning and require further attention. Watch out for: • Active drainage or pus from the wound after 3 weeks, the incision sites should be closed by this point. • Swelling and stiffness in the hand/wrist/elbow – this may mean that you have some limited lymphatic drainage; try elevating the arm on some pillows when you sit and performing some hand/finger exercises • Severe unresolved pain in the shoulder joint after 6 weeks Rehabilitation after Rotator cuff repair Rotator Cuff Exercises for Weeks 1 – 6 Physical Therapy will be vital to facilitate recovery and provide the best guidance. For the first 6 weeks, patients need to refrain from any aggressive movement or weight lifting. Initial Physical Therapy sessions are very important for preventing injury and for gradual restoration of movement. In the first several sessions, the therapist will perform the arm movements for the patient (passive motion) so as not to strain any of the repaired muscles and tendons Pendulums • Brace against a supportive surface (like a kitchen counter or dining table) • Allow the surgical arm to hang down with just the weight of the arm • Move your body back by bending your knees until the arm begins to swing around passively • Go clockwise, then counterclockwise • Perform 2 sets of 20 repetitions Table Slides • Rest your hand and forearm on a towel placed in front of your dining table • Lean forward with your body and allow your arm to move forward until you feel a gentle stretch and hold at the end for 5 to 10 seconds • Keep your shoulders relaxed, do not shrug your shoulders • Perform 3 sets 10 reps Shoulder Flexion passive range of motion • Lie on your back • Using the strength of your non-surgical arm, bring your surgical arm overhead, hold at the end for 5 to 10 seconds • Keep your shoulders relaxed, do not shrug your shoulders • Perform 3 sets 10 reps Shoulder External Rotation passive range of motion • Lie on your back, with your surgical arm’s elbow by your side • Hold a lightweight stick with both hands • Using the strength of your non-surgical arm, rotate your surgical arm outwards into a gentle stretch • Hold at the end for 5 to 10 seconds • Keep your shoulders relaxed, and keep your elbow by your side • Perform 3 sets 10 reps Your physical therapist may also direct you to work on improving your wrist/elbow and grip strength. Rehab 6 to 12 weeks post-op Most patients will discontinue wearing the sling after week 4 to 6. This will also be the time in which patients will begin moving the arm, first with some help (therapists call this “active assisted” range of motion), then progressing independence with movement (“active”). Shoulder Exercise for Weeks 6 to 8 Active Assistive Exercises (Flexion, Abduction, External Rotation) The goal is to gradually get your surgical shoulder to move with support from your other arm. • With both hands, hold onto a stick • Using the help of the good arm, push your surgical hand: • Straight up and forward (flexion) • Up to the side (abduction) • With your elbow by your side, rotate the arm (external rotation) • When first starting, use your good arm to push most of the weight, then gradually do more with the surgical arm granted there is no pain • Perform 3 sets 10 reps holding for 5 seconds. Flexion with stick Abduction with Stick External Rotation with Stick Isometrics • With your elbow by your side, press a towel with your fist into the wall in each of these directions gradually until muscle activation is felt in the shoulder • Perform 3 sets 10 reps holding for 5 seconds Shoulder Exercises Week 8 to 12 Resisted Shoulder External and Internal Rotation External Rotation Shoulder Internal Rotation • Stand with your elbow to your side and hold onto a resistance band • External Rotation: take the resistance band and rotate the arm outwards • Internal Rotation: take the resistance band and rotate the arm towards your center • Gradually progress resistance, discontinue or decrease resistance if you feel shoulder irritation • Perform 3 sets 10 to 15 reps Other typical exercises performed during weeks 8-12 • Bicep curls • Triceps extension • Wrist flexor/extensor curls • Resisted shoulder extension • Resisted cable row pulls • Wall slides • Resisted internal/external rotation at 90 degrees of shoulder abduction Shoulder Rehab 12 weeks post-op About 3 months or 12 weeks after surgery, patients should be able to raise their arm on their own and be able to lift lightweight objects up to 5 pounds. Exercises past the 12 weeks should be gradually progressed with consideration of how the shoulder feels. Patients should still have routine follow-ups with a physical therapist to determine the intensity of the exercise. The strengthening program going forward should focus on movements for returning to job duties and previous active hobbies. Even if shoulder pain has mostly subsided, the tendons still need time to heal. Returning to Work After Rotator Cuff Repair Most rotator cuff repair patients will expect to be rested for several weeks. People who have a desk job may return to work sooner whereas a manual labor professional may be out for up to 3-6 months. Depending on the progression your surgeon may decide the appropriate time to return to work.

OVERVIEW Fractures (Broken Bones) of the thigh, knee and leg, are common from both minor and major accidents. These are incapacitating in the short term as they commonly require the use of crutches, casts and modifications of activities as well as time off work and driving restrictions. DESCRIPTION Lower limb fractures occur from either direct trauma or indirectly from forces applied to the limb (eg twisting injuries). The type of fracture depends on the size and direction of the injury to the limb. Condition Low energy injuries (such as falls from a standing height), usually result in less complex fracture patterns and less soft tissue injury. Typical symptoms of a fracture include: • Pain • Swelling • Deformity • Difficulty weight bearing/walking Lower energy injuries can be missed and may be passed off as ‘sprains’ or ‘strains’. If you have had an injury that is not responding to treatment, it is advisable to see your doctor and obtain X-Rays to rule out an occult fracture. Higher energy injuries (such as motorcycle and car crashes) typically fracture bones in multiple places, into smaller pieces, and commonly disrupt the soft tissues resulting in large amounts of bruising and swelling. These can be challenging to treat and frequently require surgery to restore the bones to their anatomical position to make healing quicker and your function better in the long term. TREATMENT The treatment of lower limb fractures requires careful tailoring to the individual patients demand and the type of fracture sustained. Non-operative treatment of lower limb fractures may involve: • Crutches • Braces • Plaster Casts • Orthotic Shoes • Activity Restriction • Physiotherapy Dr. Jain always encourages non-operative treatment whenever possible ,however many fractures do much better with surgical intervention as surgery can speed up recovery and improve the short and long term outcome. As there many different types of lower limb fractures, there are a large range of surgical options that can be used, these can include: • Plates + screws • Wires • Rods/Nails • External Fixators Sometimes a combination of these is used, and Dr. Jain will discuss the surgical plan with you pre-operatively. He uses the latest technology in minimally invasive percutaneous orthopedic trauma implants, to give you the best outcome possible with the least amount of scarring and soft tissue injury. After surgery, Dr. Jain will discuss your operation as well as plan your rehabilitation in line with your goals and expectations. He uses a highly qualified team of physiotherapists and rehabilitation specialists to get you back to your activities as quickly as possible. Dr. Jain has extensive experience treating fractures, he has completed Training at Cascais Hospital in Lisbon (Portugal, Europe) with world recognized leaders in Orthopedic Trauma Surgery, and has worked as an Orthopedic Joint Replacement & Trauma Consultant at Tata Hospitals. He routinely attends conferences and visits trauma centers worldwide to refine his skills and stay on top of the most recent advances in trauma surgery. He is also actively involved in various trauma research projects and regularly teaches junior doctors.