Shoulder Injuries: Pain Reaching Overhead

doac60The shoulder is a very resilient joint. It can take alot of abuse, repetitive use, and even small strains and mild to moderate osteoarthritis without bothering us for attention. However, at somepoint, if the injury is significant, or if small traumas add up overtime, the shoulder begins to scream out for attention and block us from doing certain motions–typically reaching overhead, or carrying things away from the body. Even sleeping on the shoulder, or performing prolonged static activities such as holding a book to read, driving, or washing mirrors and windows can be intolerable.

Some of my patients become so stiff that the shoulder seems to be stuck in position, preventing them from reaching, combing their hair, putting on clothes or even brushing their teeth with the affected arm.

There are many structures in the shoulder which can be injured–the rotator cuff which consists of 4 tendons to the muscles that run all of the arm’s overhead activities.; the biceps tendon which left-shoulder-anatomyattaches to the muscle that flexes the forearm and hand uptoward the shoulder; the main ball and socket shoulder joint (glenohumeral joint) and the smaller joint at the end of the collarbone that connects to the shoulder blade (acromioclavicular or AC joint), or the bones of the upper arm (humerus) and shoulder blade (glenoid) or collarbone itself (clavicle).ex4

Rotator cuff injuries can come in the form of a tendonitis (swelling/irritation), a partial tear or a complete tear. Sometimes the undersurface of the acromion (the tip of the shoulder when you touch the top of your shoulder) can rub on the underlying rotator cuff tendons and cause irritation called “impingement” or shoulder bursitis.

Most minor shoulder injuries–after a thorough physical examination to rule out any larger issues–can be treated with rest, gentle stretches, anti inflammatory medications such as Advil or Aleve, and in some cases physical therapy. More major injuries, or those that do not seem to get better after a few weeks many require investigation.

Investigations include an ultrasound, Xray or MRI of the shoulder to view the structures and determine the exact nature of the symptoms. Sometimes a CT scan, or an MR-arthrogram where dye is injected into the shoulder to better see the joint structures, are used.doac58

If a full thickness rotator cuff tear is found and the symptoms and physical examination match well with the location of the tear noted on the investigations, surgery may be recommended. Partial thickness rotator cuff tears do not typically require surgery, although some progress to full thickness tears over time. Impingement syndrome, if severe, may require arthroscopic surgery to decompress or remove some of the bone at the undersurface of the acromion and prevent further irritation or compression of the underlying tendons during overhead activity.

Nonoperative treatments for shoulder injuries range from home stretching and rest, to cortisone injections and physical therapy modalities. An injectin of an anesthetic into the AC joint, the glenohumeral joint, or in the space beneath the acromion can help identify which area is causing symptoms to better determine the diagnosis and the best treatment.

There are some excellent exercises for shoulders that can help prevent “frozen shoulder” syndrome or severe stiffness after injuries. See our website for more information at

The Weekend Warrior Syndrome–Avoiding Injury

Weekend warriors: According to, a weekend warrior is a person who holds a regular job during the week which restricts their ability to partake in adventurous or physical activities, and thus plans epic weekend adventures to compensate leaving them susceptible to injuries as a result of lack of training, fitness or due to unconditioned physical training or skill.

For example, a busy executive spends 12 hours a day at work, Monday through Friday, and then on the weekend goes skiing, parachuting, plays in a hockey tournament, goes windsurfing or decides to do a marathon with minimal training.

Aside from the stiffness and muscle pain that will now take him the entire next week to recover from, a weekend warrior is at risk of certain injuries that may be debilitating and even require surgical treatments. lists eight typical weekend warrior injuries to be aware of:

1. Shoulder rotator cuff injuries

2. Elbow tendonitis IMG_9090

3. Knee arthritis

4. Hip arthritis

5. Knee cartilage tears

6. Anterior cruciate ligament tears of the knee

7. Achilles tendonitis

8. Low back strain

Over the next few blogs, I’ll address each of these common weekend warrior injuries. Sure, the same injuries happen to well trained and conditioned athletes, but avoidance of these conditions for an occasional adventure sports enthusiast is not as difficult as you might believe.

Regular sport-specific conditioning, a general exercise or core conditioning program, and stretching before and after physical activities may help prevent injury to joints, ligaments, tendons and muscles.

New Drug to Renew Cartilage in Osteoarthritis Patients Promising

Rush University Medical Center is conducting the nation’s first clinical study of an innovative stem cell drug, Cartistem, to repair knee cartilage damaged by aging, trauma or degenerative diseases such as osteoarthritis. According to Science Daily, Cartisem is manufactured from the controversial umbilical cord stem cells. It is less of an ethical dilemma than other sources of stem cells as newborn infants no longer need their umbilical cords and they tend to be disposed of by pathologists after a brief inspection to ensure the newborn had a healthy placenta and cord.

The stem calls, which are the building block cells of most important organs and structures in the body, are harvested and transformed into cartilage cells and injected into the area of lost cartilage during a surgical procedure.

Science Today interviewed the Chief Investigator, Dr. Brian Cole, who says “Finding a biological solution for cartilage regeneration in orthopedics is one of the fastest growing areas of research and development in our specialty–Rush is spearheading this field of research with the ultimate goal of safely improving outcomes and sparing patients from having more complicated surgery at a relatively young age.”knee_cart_surg_intro01

According to Cole, this treatment is designed for patients with small areas of lost cartilage or exposed bone in joint such as the knee, not for patients with diffuse generalilzed osteoarthritic changes.

So an osteochondral injury–where a “chunk” of cartilage has been knocked off the bone surface by trauma; or a smaller area of worn-away cartilage are best treated with this new compound.

Although not yet available outside of clinical trials, and certainly not on the market in Canada, Cartistem is a promising idea for a disease of which there is no known cure — osteoarthritis.


Bone and Joint Health Supplements?

Many patients ask about bone and joint supplements–some have chondrglucoitin, some have glucosamine, others have hyaluronic acid, and some I simply can’t recognize. Past research done several years ago determined that some of these components of normal joint cartilage, when taken by mouth, might be chondro-protective–preventing damage or wear of the cartilage that lines the joint. The wearing away of this cartilage is the process we term osteoarthritis, or “wear and tear” arthritis.

It so happens that the glucosamine may simply be too big a molecule to get into the joint from the bloodstream and likely doesn’t do a thing to protect your cartilage if you ingest it. Other studies, however, have suggested it acts like a natural anti inflammatory of sorts, to decrease inflammation and therefore reduce the symptoms of osteoarthrits….yet not change the speed a joint is deteriorating over time.

So what’s the recent thinking on all of these supplements?

In the International Journal of Rheumatology (Vol 2011, article 17), the authors report that the ability for articular cartilage to regenerate is very limited. It’s believed that the inability of cartilage to adapt to wear and tear is that it has no ability to repair itself with the same type of cartilage you are born with. Knee cartilage does seem to make a fibrocartilage type of scar in some patients, but studies looking at this scarred cartilage tell us it is not normal hyaline cartilage. The cells that make cartilage have limited blood supply which is believed to be the reason for their inability to repair.

From the clinical trials using glucosamine, however, it can now be concluded that long-term treatment with glucosamine reduces pain, improves function/mobility of the joint, reduces progression of osteoarthritis, and reduces risk of total joint replacement. Chondrointin sulfate has been shown in many different studies to provide symptom relief for patients with osteoarthritis and may slow the rate of progression of osteoarthritis if used together with glucosamine.

A more recent study published in the Scientific World Journal in 2012 shows that long-term treatment of Glucosamine Sulfate may reduce the dependence of antiinflammatory medication usage and delay the disease progression.


Although the mechanism of action of these drugs is not clear, and no appreciable increase in blood or cartilage levels of these substances was found to be statistically significant, there is still much research that supports the use of chondroitin sulfate and glucosame in symptom management and overall joint health.

Viscosupplementation by direct injection of hyaluronic acid (Monovisc, Synvisc, Orthovisc) has been shown to dramatically decrease the symptoms of osteoarthritis in patients, lasting up to 6 or 8 months in many cases.Viscosupplementation-380-240

Fore more information on viscosupplement injections, give us a call at the clinic for more information. 647.347.7218.



Music as Medicine!

Yes, we play music in the operating room–not to rock out, but to relax. As a somewhat stressful place to work, music has a tendency to help relax and motivate in any workplace. Even the OR.

But what about the patients? Is music a good adjunctive therapy for patients recovering from surgery?

A new study published by the University of Kentucky found that music is of benefit to patients before, during and after surgery and may reduce pain and recovery time.

Patients tend to less anxious and recover faster when music is played. They also required less sedation, anesthetics and pain medications during their stay.

Characteristics of the music are also important in effective music therapy. Tempo, rhythm and volume seem to play a factor in patient response to music. As you can imagine, calm, slow, gentle music was most effective.


It takes music science to a new level. Perhaps Operating Room and Intensive Care DJ’ing will eventually become a real gig!

If you want to try out music therapy on your own, iTunes has a free little app called Songza that allows you to pick music for your mood and time of day. It then decides what tunes to feed you.untitled

Check out



Ice It! How Ice Therapy Can Speed Your Recovery

icetherapyIce therapy, also called “Cryotherapy”, is useful at reducing pain, swelling and improving the speed of recovery after orthopaedic surgery. There are several studies in the literature which demonstrate the effectiveness of cold treatment for patients recovering from knee and shoulder surgery.

One of the oldest and simplest forms of treatment, ice has been used for all types of soft tissue injuries and represents one of those “old wives’ tales” that is actually true. Physiotherapists and sport trainers have used ice for decades to treat acute soft tissue injuries in athletes and soldiers.  The abbreviation “RICE” is used in medicine to instruct patients to Rest Ice and Elevate an injured limb.11-0494_iceman_unit_model_1100_lowres

I have been prescribing cryotherapy for my post operative knee and shoulder patients since beginning practice in 2004. Initially I found it most effective in patients after ACL and other forms of soft tissue reconstruction surgery. More recently I have noted good success in using an “ice machine” in patients after shoulder arthroscopy for rotator cuff repairs, labral tears and acromioplasty. And I’m not alone.

The American Board of Orthopedic Surgeons issued Guidelines for Treatment of Rotator Cuff Problems (AAOS Now, Jan 2011, Vol 5 no 1) stating “local cold therapy is beneficial to relieve pain after rotator cuff surgery”.

Recently, the use of cold therapy after Total Knee Replacement has been suggested. In a meta analysis reported in Orthopedic Nursing (2011, Vol 30 No 1), eleven studies were reviewed on the effects of continuous cold flow therapy on blood loss, pain, swelling, and range of motion of the operative knee versus an ice bag or the use of traditional narcotics. Six of the studies showed significantly lower pain scores in the cold compression group than in a control group, including epidural analgesia, a Jones bandage, narcotic administration, and crushed ice. It appears to provide benefits for patients undergoing a total knee replacement.

Ice therapy can be delivered via an ice machine and cryocuff consisting of a cooler filled with ice and water circulating the cold mixture through a waterproof sleeve or brace applied over the shoulder or knee on top of the surgical bandages. This can be worn for 8 to 12 hours a day if tolerated. Attention must be paid to the temperature controls on the unit to avoid over-cooling the skin.

For more information on “ice machines” and “cryotherapy units”, please call the office at 647.347.7218 or visit and  or . We can help you obtain a unit for your post operative recovery needs.

Check out this video:

Is Canada’s HealthCare System Failing Us?

With increased longevity goes an increase in the number of Canadians living with chronic illness and an aging population requiring more care than a younger population with fewer illnesses. So as we age, so do all of Canadians. Fewer of us die, therefore the burden on the healthcare system grows.


We already know that our current healthcare system is not meeting the needs of Canadians. The following key problems prove that there is a decline in the efficiency and productivity of the system–we have issues providing timely access to care. Check these statistics out:


 Twenty percent of Canadians state their time has been wasted due to poorly organized or badly coordinated care.

 12% of Canadians report their specialist was missing basic personal information at the time of their scheduled visit.

 One in four reports that their regular doctor did not seem up to date on the outcomes of a specialist visit based on their own referral.

 In the past two years, 44% of Canadians visited an emergency room and 47% of those visitors say they could have been treated by a primary care physician if one were available.

 Canadians have the highest rate of emergency department use among 11 OECD countries.

 65% of Canadians believe access to weekend and holiday care is somewhat difficult to attain. Canadians who find it “very easy” to contact doctors on holidays and after hours are far more inclined to rate the quality of care they receive as excellent.

 Fewer than 45% of Canadians report being able to get an appointment with a primary care physician the same day their request is filed.

 16% of Canadians have no primary care provider (family doctor).

 46% of Canadians say they would use a walk-in clinic rather than having to wait for a doctor’s appointment.

Healthcare as a whole is Canada’s largest business sector, yet it’s certainly not run like an efficient, effective business. In fact, if you were to rate the healthcare system using business grading methods, it would fail in the number one output for success of any business: customer satisfaction.

“Soaring health care costs, increasing rates of chronic illness and an aging population leave Canada struggling to meet the growing demand for quality health care. This is a time for new and innovative solutions to old problems.”

Why Do We Wait So Long For Surgery in Ontario?

One of the most frequent complaints I hear from patients relates to waiting times for surgery and diagnostic studies like an MRI. Although we have the ability to expedite patients with serious conditions who need immediate care, the elective waiting list for nonurgent conditions and routine testing can be frustrating for most patients.

In Canada, with our public health care system, there is no way to “jump the line” and receive procedures sooner by paying out of pocket, which we see in two-tiered health systems like the UK or in private systems like s57the US. In Canada, patients are treated equally regardless of socioeconomic status .

The reasons we have to wait for tests or surgery are numerous but primarily related to the availability of resources. Even with MRI units running 24 hours per day, 7 days per week, there are simply not enough of these million dollar machines to offer immediate access to patients requiring testing.

As for surgery, Ontario hospitals are constrained by health care allocation budgets which dictate the number of surgeons, nurses and anesthetists who are able to offer surgical services based on the number of operating room blocks or units that are allotted to a hospital. Most surgeons operate one to two days per week and spend the other 3 to 4 work days in the office seeing patients or in hospital outpatient clinics caring for post operative or injured patients.  Even if we, as surgeons, have extra time to operate in our personal schedules, the hospitals we work for may not have the resources in the budget to offer us more “OR time”–including nursing staff, operating room space and hospital beds to care for post operative

The average wait times for various surgical procedures in Ontario:

Procedure                     Provincial Average   Humber River

Total Knee Replacement        230                             153

Total Hip Replacement           186                             130

Knee Arthroscopy                   148                               84

Shoulder Surgery                    205                               74

Average Wait Times in the Emergency Room
Provincial Average for total time spent waiting to be treated for complex conditions is 5.7 hours, for minor uncomplicated conditions is 2.2 hours. The total time spent in the emergency room for complex conditions is 10.9 hours and for minor conditions is 3.7 hours. Humber River Hospital reports very similar wait times across these same parameters.

The Ontario provincial average wait time for an MRI is 83 days (71 at Humber River). The alternate method of obtaining an MRI which is becoming more popular is to drive to Buffalo, New York and pay between 500 and 1500 for MRI testing.

The unfortunate bottom line is that we have a public funded system with a limited amount of resources and even at more than full capacity, the system is unable to eliminate wait times for non-emergency patients.


The Benefits of Physiotherapy

doac45aPhysiotherapy is not just for patients who have recently had surgery, although it does offer a great way to regain motion, strength and eliminate pain, swelling and weakness.

People with back pain, sport injuries, chronic fatigue and even those starting a new weight loss or fitness program can benefit from the various physical therapy modalities offered in most rehab and physio clinics.

According to the Vancouver Physiotherapy and Sports Clinic, physical therapy has come a long way since the early nineteenth century when massage and manipulation were seen as being outside of the realm of medical science. Physical therapy traditionally involved the use of heat, electrical stimulation and water applications to aid movement and function. After World War II, physiotherapists slowly began to align themselves with medical practitioners and today, the profession is a field within the realm of medical practice with referrals from not only chiropractors and sport trainers, but doctors, physiatrists and surgeons alike.

Today physiotherapies include a wide range of treatments from traditional heat therapy and electricity (TENS) to manipulation, shock wave therapy, and exercises including stretches, strengthening and cardio. Some physical therapist employ accupuncture, spinal traction and parafin treatments. Many physical therapy clinics employ or are affiliated with chiropractors who engage in spinal and extremity manipulation and adjustments.

As the lines between “alternative” therapies and mainstream medicine blur in this era of health consciousness and preventive medicine, physiotherapists are an integral part of the holistic healthcare experience.

Visit Downsview Orthopaedic and Arthritis Centre for more information.

PRP Injections Relieve Knee Pain

PRP (platelet rich plasma) injections have been found to relieve pain in patients with tendonitis and joint pain. Platelet Rich Plasma is made from a portion of the patient’s own blood.The activated platelets are injected into the abnormal tissue, releasing growth factors that recruit and increase the proliferation of reparative cells.

acp-therapie-schematische-darstellung prp prp1Platelet activation plays a key role in the process of wound and soft tissue healing. The use of platelet rich plasma (PRP), to promote healing of injured tendons, ligaments, muscles, and joints, can be applied to various musculoskeletal problems.   PRP was used as early as the 1990s in maxillo-facial and plastic surgery. PRP injections are prepared from one to a few tubes of the patient’s own blood with strict aseptic technique. After being centrifuged, or “spun down”, the activated platelets are injected into the abnormal tissue, releasing growth factors that recruit and increase the proliferation of reparative cells.   Several clinical studies have demonstrated that PRP injections can improve function and decrease pain in the elbow, wrist, shoulder, hip, knee, and ankle. Early work is also showing promise for osteoarthritis.   The side effects of PRP injections are rare as it uses the patient’s own blood products. Rest followed by gentle stretching is all that is required after PRP injections.

Other injections we use in our clinic for tendon and joint symptoms include cortisone and hyaluronic acid (Monovisc, Synvisc, Orthovisc).


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