Alton Barron: Shoulder, Elbow, Wrist, and Hand: Diagnosis, Treatment, and Surgery

Orthopedic Surgery and Upper Extremity

• Orthopedics is a broad and specialized field 
  • Even doctors may know little about it outside of their specific area
• Upper extremity surgery is more creative and variable than other areas of orthopedics 
  • Less cookie-​​cutter, more individualized
• In the 1990s, minimally invasive orthopedic surgery was just starting to take off 
  • Knee arthroscopy was the first major development
  • Shoulder arthroscopy was still primitive 
    • Open shoulder arthroplasty, open instability repairs, open labral repairs
    • Early arthroscopic repairs had high failure rates
• Evolution of devices and techniques 
  • Transition from metal to plastic to braided polyester anchors
  • Tiny drills and suture anchors allow for more precise repairs
• Understanding of the clinical relevance of certain injuries has evolved 
  • Example: SLAP tears (labral tears) were once considered benign, but now recognized as a significant issue

Anatomy and Evolution of the Upper Extremity

• Standing upright during evolution allowed for greater complexity and functionality in the upper extremity 
  • Force multiplier in terms of dexterity and capability
• Understanding the anatomy of the shoulder and upper extremity is crucial for orthopedic surgery 
  • Labrum: a ring of cartilage that surrounds the shoulder socket, providing stability and cushioning
  • SLAP tear: a specific type of labral tear that occurs at the top of the shoulder socket, often affecting overhead athletes 
    • Previously considered benign, now recognized as a significant issue that can cause secondary problems if left untreated
      Orthopedics and Shoulder Stability
• Human body sacrifices stability for mobility and dexterity 
  • Joints like the shoulder and thumb are less stable but more versatile
• Shoulder joint is a delicate balance of mobility and stability 
  • Glenoid (socket) is shallow, allowing for a wide range of motion
  • Stability relies on soft tissues like ligaments, tendons, and muscles

Rotator Cuff Muscles

• Four muscles make up the rotator cuff: 
  • Supraspinatus: initiates elevation of the shoulder
  • Subscapularis: helps with reaching behind the back and pulling the hand away
  • Infraspinatus: external rotator, important for activities like tennis, golf, and weightlifting
  • Teres minor: external rotator, also important for stability in various activities

Rotator Cuff Tears

• Can be classified as degenerative or traumatic 
  • Degenerative tears more common in older individuals
  • Traumatic tears more common in younger individuals, often involve bone being pulled off with the tendon
• Tears can occur in any of the four rotator cuff muscles 
  • Can be in the muscle, at the junction between muscle and tendon, or a complete separation of the tendon from the bone

Dislocations and Subluxations

• Dislocation: joint comes out of place and needs to be put back in
• Subluxation: incomplete dislocation, joint comes out but pops back in easily 
  • More common with recurrent dislocations or stretchy/​​compliant tissues
    Glenohumeral Joint and Labrum
• Glenohumeral joint: where the humerus meets the scapula 
• Labrum: rubbery, calamari-​​like structure surrounding the joint 
  • Provides static stability to the shoulder
  • Works like a suction cup, holding the humeral head in place
  • Can tear from trauma or repetitive use

Subluxation and Dislocation

• Subluxation: partial dislocation of the shoulder joint 
  • Can occur without tearing the labrum in individuals with loose joints
• Dislocation: complete separation of the humeral head from the glenoid fossa 
  • Often results in tearing the labrum and/​​or ligaments
  • Requires significant force or unnatural leverage

Rotator Cuff and Biceps Tendon

• Rotator cuff: group of muscles and tendons that surround the shoulder joint 
  • Provides dynamic stability to the shoulder
• Biceps tendon: connects the biceps muscle to the shoulder and forearm 
  • Long head of the biceps tendon can become inflamed and cause pain
  • Can tear from wear and tear or acute trauma, leading to a “Popeye muscle” appearance

Shoulder Injuries in Athletes

• Overhead athletes, weightlifters, and swimmers are at risk for shoulder injuries 
  • Dynamic stabilizers can fatigue, leading to subluxations and secondary inflammation
  • May require rest, rehabilitation, and sometimes surgical intervention to restore stability
    John Elway and Shoulder Pain
• John Elway, former Denver Broncos quarterback, experienced shoulder pain and considered retirement
• Shoulder pain related to superior labrum tear and biceps tendon issues

Superior Labrum and Biceps Tendon

• Superior labrum tear can cause instability and inflammation in the biceps tendon
• Some orthopedic surgeons may snip and reattach the biceps tendon to alleviate pain (tendinesis)
• A good superior labrum repair can often resolve biceps tendon issues without tendinesis

MRI Findings and Shoulder Issues

• Many people have asymptomatic labral tears or rotator cuff tears
• MRI findings should not be the sole basis for surgical decision-making
• A thorough history, examination, and understanding of the patient’s activities and symptoms are crucial for accurate diagnosis and treatment

Asymptomatic Shoulder Issues and Surgery

• Generally, surgery is not recommended for asymptomatic structural shoulder issues (excluding tumors)
• However, surgery may be considered for patients with significant functional limitations due to shoulder issues, even if pain is not the primary symptom
• Example: An 86-​​year-​​old man with a dislocated shoulder and torn rotator cuff tendons regained full function after surgery, allowing him to maintain an active lifestyle for several more years
  Shoulder Pain and Injuries
• Shoulder pain can be caused by various factors 
  • Rotator cuff injuries
  • Labral instability
  • Bicep tendon injury
  • Acromioclavicular (AC) joint issues
• Acromioclavicular (AC) joint 
  • Connects the clavicle (collarbone) to the acromion (part of the scapula)
  • Commonly injured in cyclists and people who land on the outside of their shoulder
  • Separation of the AC joint is different from dislocation
• Acromion
  • Bony roof of the shoulder
  • Rotator cuff glides underneath it
  • Some people are born with or develop a bone spur, which can cause irritation and rotator cuff tears
• Bursa
  • Thin, filmy structure between the acromion and rotator cuff
  • Allows for frictionless movement
  • Can become inflamed and cause bursitis
• Genetic predispositions and anatomical differences can impact athletic performance and injury risk 
  • Example: People with certain acromion shapes may be more prone to shoulder injuries in overhead activities
  • Knowing these predispositions can help individuals tailor their activities and exercise routines to minimize injury risk
• AC joint arthritis 
  • Common in middle-​​aged individuals and beyond
  • Can be asymptomatic or symptomatic
  • Young weightlifters can develop distal clavicle osteolysis, causing cartilage disintegration and bone softening
    Shoulder Pain and Potential Causes
• Shoulder pain can have many causes: 
  • AC joint problems
  • Bursitis
  • Rotator cuff injury
  • Labral injury
  • Bicep tendon inflammation
  • Arthritis (usually accompanied by one of the other issues)
• Adhesive capsulitis (frozen shoulder) can also cause shoulder pain 
  • Common condition, but the cause is not well understood
  • Can be multifactorial and complicate diagnoses

Shoulder Exam and MRI Correlation

• A thorough exam and MRI can help identify the cause of shoulder pain
• The MRI can show the capsule, which can indicate adhesive capsulitis if it is high, tight, and thick
• A comprehensive exam can help determine the best course of action, whether it be surgical or non-​​surgical care
  Frozen Shoulder and Neck Pain
• Frozen shoulder: spontaneous, intense inflammation in the inner lining of the shoulder 
  • Can be primary or secondary stiffness
  • Old literature claimed it would get better with time, but not always the case
  • Only 1 out of 5 patients need surgery; most need physical therapy and inflammation control
• Neck pain can be referred pain from the spine 
  • Important to differentiate between shoulder and neck pain
  • Intrinsic shoulder pathology rarely causes pain below the elbow, while neck pain often does
  • C7 nerve can cause deep posterior pain under the scapula
• Treatment for neck pain 
  • Prednisone and traction can be effective
  • Low dose of prednisone can help with mild symptoms without weakness
  • Good history and physical exam can lead to accurate diagnosis without extensive imaging

Examining Shoulder and Neck Issues

• Look for atrophy, asymmetry, and abnormalities 
  • Separated shoulder can cause a visible bump
  • Nerve problems can cause indented pectoralis muscle
  • Ruptured pectoralis tendon can cause bruising down the arm, not the chest wall
    Shoulder Examination and Diagnosis
• Look for asymmetry and palpate various areas 
  • AC joint, front of the shoulder, pecs, deltoid, acromium, upper trapezius, rhomboid minor/​​major, levator
• Check range of motion 
  • Forward elevation, external rotation, internal rotation, abduction
• Test strength
  • Rotator cuff, deltoid (anterior, posterior, lateral)
• Perform provocative maneuvers 
  • Impingement sign, biceps tests (long head, distal), labrum tests (superior, anterior/​​posterior)

Surgical Treatments for Shoulder Issues

• Labrum repair
  • Approach varies depending on the type of tear (SLAP vs. complete tear)
  • More technically challenging for complete tears
  • Percutaneous approach with small incisions (1–1.5 cm)
    Exam Under Anesthesia and Shoulder Surgery
• Exam under anesthesia is crucial for assessing shoulder issues 
  • Allows for testing of static stabilizers without muscle interference
  • Helps determine if a capsulerophy (tightening of the capsule) is needed
• Importance of considering patient’s biological age and specific circumstances 
  • Precision medicine: evidence-​​informed decisions based on individual physiology
  • Conversations with patients to determine the best course of action

Shoulder Surgery Process

• Camera inserted through the back for a panoramic view 
  • Angled lenses used to see around corners if needed
• Saline used to insufflate the area, creating space for work 
  • Lower pressure (35 mercury) used to reduce postoperative pain
• Two working portals in the front for instruments 
  • Percutaneous hole made for superior labrum access
• Drilling and inserting anchors into the glenoid fossa 
  • Diameter of hole depends on anchor size (1.8–3mm)
  • Anchors inserted with pressure, not screws
  • Braided polyester anchors used for strength and stability
    Rotator Cuff Repair in Athletes
• Examining the cuff during surgery 
  • Survey the joint, cartilage surfaces, rotator cuff insertion, and biceps
  • Identify inflammation, tears, and abnormalities
• Importance of early diagnosis in athletes 
  • Pain is evaluated and addressed quickly
  • Allows for early intervention and prevention of further damage
• Rotator cuff tears in athletes 
  • Overhead athletes: superspinatus tear most common
  • Linebackers, falling downstairs: subscapularis tear
  • Throwing athletes: internal impingement at junction of infraspinatus and superspinatus
• Connection to Tommy John surgery (elbow)
  • Shoulder pathology can lead to overcompensation and torque on the elbow
  • Torn medial collateral ligament in the elbow can lead to overcompensation in the shoulder
• Advances in rotator cuff repair 
  • Early diagnosis and intervention
  • Improved surgical techniques and understanding of biomechanics
  • Full thickness tears can be minimally symptomatic, while partial thickness tears can be very symptomatic
  • Repair depends on the size, location, and symptoms of the tear
    Partial vs. Full Thickness Tendon Tears
• Partial thickness tear: half the tendon torn 
  • High-​​level throwing athletes cannot perform with this injury
• Full thickness tear: entire tendon torn
• Muscle bellies can be torn in strong athletes, such as football players 
  • Interstitial tearing at the muscular tendon junction
  • Can heal without intervention, just time and anti-​​inflammatory treatment

Stem Cells and PRP in Tendon Healing

• Anecdotal evidence of stem cells and PRP helping in muscle tears
• No clear randomized controlled trials (RCTs) for stem cells in tendon healing
• Many poorly designed studies and financial interests in stem cell treatments
• Natural history of tendon injuries without treatment is not well understood 
  • Some studies suggest rotator cuff tears do not heal spontaneously

AC Separation in the Shoulder

• AC joint: where the clavicle meets the acromion
• Injuries can range from a sprain (type 1) to a full tear of the ligaments (type 3)
• Type 1: sprain of the AC joint, usually heals on its own with time and rest
• Type 2: partial tear of the coracoclavicular ligaments, may require surgery
• Type 3: complete tear of the coracoclavicular ligaments, often requires surgery
• Treatment often involves wearing a sling to relieve weight from the shoulder

Challenges in Stem Cell Research for Tendon Healing

• Standardizing the process of capturing and processing stem cells
• Ensuring consistent treatment across different companies and clinicians
• Conducting well-​​designed, controlled studies to determine the effectiveness of stem cell treatments
  Shoulder Injuries and Treatments
• AC ligament tears and treatment 
  • Grade 2: partial tear, usually treated non-operatively
  • Grade 3: complete tear, may require surgery
  • Treatment options depend on severity and patient preferences
• Sternoclavicular joint injuries 
  • Less common than AC joint injuries
  • Can be life-​​threatening if dislocated behind the manubrium
  • May require reconstruction with a tendon from the forearm
• Total shoulder replacement 
  • Indication: severe pain due to worn down cartilage
  • Outpatient procedure for most patients
  • Age not a factor; oldest patient was 97 years old
  • Some people just develop arthritis without a specific cause
    Shoulder and Elbow Anatomy and Injuries

Shoulder Replacement

• Shoulder osteoarthritis can lead to dysfunction and pain
• Shoulder replacement involves:
• Removing the arthritic head of the humerus
• Smoothing the glenoid and inserting a high-​​density polyethylene component
• Inserting a cobalt chromium or alloy head into the humerus
• Reattaching the subscapularis tendon
• Post-​​surgery, patients can perform most activities except heavy weightlifting

Elbow Anatomy

• Humerus, radius, and ulna make up the elbow joint
• Tendons originate above the joint and attach below it
• Biceps tendon attaches to the radius
• Lateral side (outside) of the elbow has muscle tendon units attaching to the lateral epicondyle
• Tearing in this area is common in tennis elbow (lateral epicondylitis)
• Medial side (inside) of the elbow has flexor pronator muscles attaching to the medial epicondyle
• Tearing in this area is common in golfer’s elbow (medial epicondylitis)
• Triceps tendon attaches to the tip of the elbow
• Olecranon bursa is located over the tip of the elbow and can become inflamed
  Elbow Injuries and Treatments
• Elbow injuries can occur in various sports and activities 
  • Tennis elbow (lateral epicondylitis) — inflammation in the tendon due to one-​​handed backhands
  • Golfer’s elbow (medial epicondylitis) — inflammation in the medial tendon due to overhitting or hitting objects
• Age range for treating these injuries is typically 40–60, but it’s increasing due to people staying active
• First line of treatment for elbow injuries 
  • Rest, stretching, and strengthening
  • NSAIDs (nonsteroidal anti-​​inflammatory drugs) by mouth
  • Cortisone injections in some cases
• Surgical cases for elbow injuries 
  • Ruptured distal biceps tendon — primary supinator of the forearm 
    • Surgery involves reattaching the tendon
  • Tommy John surgery (medial collateral ligament reconstruction) — for elite throwers who experience a significant loss of throwing speed 
    • Not necessary for non-​​athletes or casual players

Common misconceptions
* Tommy John surgery is only for elite throwers, not for casual athletes or non-athletes
* Strengthening surrounding muscles can help protect ligaments from injury
Examining the Elbow

• Elbow: complicated joint with many components
• Carrying angle: check for symmetry, swelling, or atypical features
• Distal biceps rupture: common in CrossFit, can be identified by a shifted biceps contour
• Lateral epicondylitis (tennis elbow): pinpoint pain on the lateral epicondyle, can be identified by palpation and resisted wrist extension
• Medial epicondylitis (golfer’s elbow): tenderness on the medial epicondyle, pain during resisted wrist flexion
• Range of motion: important to assess flexion and extension, functional arc of 100 degrees needed for daily activities
• Triceps tendonitis or partial rupture: can be identified by pain during resisted elbow extension from a flexed position

Ideal Position for Triceps Workouts

• Literature suggests humeral flexion to stretch the triceps
• Overhead triceps exercises may be more effective than those done with the arm down

Hand and Wrist Surgery

• Highly specialized field, requiring additional fellowship training after completing orthopedics or plastics program
• Important for mediating contact with the outside world and extremities
  Advancements in Hand Surgery and Treatment
• Microvascular techniques developed in the past 
  • Allowed for better treatment of lacerations, war injuries, and nerve/​​blood vessel-​​related issues
  • Reduced the need for amputations
• Hand transplantation has advanced significantly in recent years 
  • Involves a large team of surgeons and specialists
  • Results are mixed, and ideal candidates are limited
  • Generally, bilateral hand amputees are the best candidates
• Electrical prostheses linked to the brain have improved hand function for some patients
• Muscle transfers from other parts of the body can restore some primitive function in the hand

Common Hand Injuries and Treatments

• Injuries can be acute (traumatic) or chronic (wear and tear) 
  • Acute injuries often involve fractures, dislocations, and ruptures
  • Chronic injuries often involve arthritis and sports-​​related issues
• Scaphoid bone fractures are common and difficult to heal 
  • Often caused by hard falls with the wrist in a specific position
  • Can be difficult to detect on X‑rays, MRI is the preferred imaging modality
  • Treatment has evolved over time, with non-​​operative and operative options available
  • Operative treatment may involve specialized screws to promote healing
    Herbert Screw and Scaphoid Fracture Treatment
• Herbert screw: game changer for treating scaphoid fractures 
  • Compresses bones together for better healing
• Different approaches to scaphoid fracture treatment 
  • Full incision and use of jigs
  • Percutaneous approach with small incision 
    • Faster healing and quicker return to movement
• Non-​​operative treatment for scaphoid fractures 
  • Nondisplaced fractures can heal with immobilization
  • Cast or splint may be used
  • Considerations for treatment include patient’s needs and comorbidities

Hand Anatomy and Nerves

• Median nerve: runs along the thumb side of the wrist
• Ulnar nerve: runs along the pinky side of the wrist
• Radial nerve: sensory nerve along the backside of the hand
• Median nerve size varies, can be up to a centimeter wide in large hands
• Over 60% of higher cortical neurons devoted to hand function

Carpal Tunnel Syndrome

• Carpal tunnel: created by a Roman arch of bones and a thick transverse carpal ligament 
  • Contains nine flexor tendons and the median nerve
• Carpal tunnel syndrome: compression of the median nerve due to swelling, inflammation, or injury 
  • Symptoms include numbness and tingling in the thumb, index, middle, and half of the ring finger
• Motor functions of median and ulnar nerves 
  • Median nerve: controls thumb, index, middle, and half of the ring finger
  • Ulnar nerve: controls other hand functions
• Carpal tunnel syndrome can be caused by pregnancy, arthritis, or other factors causing swelling or compression of the median nerve
  Carpal Tunnel Syndrome and Typing
• Most people don’t get carpal tunnel just from typing 
  • Massive class action lawsuit against IBM couldn’t prove typing caused carpal tunnel
  • However, if you already have it, typing can exacerbate it
  • Ergonomics are important to prevent exacerbation

Ulnar Nerve Importance

• Ulnar nerve supplies almost all the small muscles of the hand 
  • Allows us to spread fingers apart, pull fingers together, and perform complex hand movements
• Cutting the ulnar nerve at the wrist can severely limit hand movement

Opposable Thumb and Evolution

• Opposable thumb is the primary difference between humans and lower primates 
  • Allowed us to make tools and develop our brains
• Our hands are more primitive in structure compared to our feet, which have adapted for bipedal walking

Common Hand and Wrist Injuries

• Acute traumatic events: fractures and dislocations
• Wear and tear injuries: usually start in middle age and progress into older age
• Degenerative arthritic problems: vary among individuals based on genetics and lifestyle

Common Fractures

• Distal radius fracture: most common, occurs when falling on an outstretched hand
• Both bone forearm fracture: common in kids falling off jungle gyms
• Nightstick fracture: direct blow to the ulna, often from a billy club or similar object

Chronic Hand and Wrist Injuries

• Overuse patterns: tendonitis and tenosynovitis 
  • Inflammation in the tendon and degeneration of collagen fibers
  • Can cause chronic pain if not addressed
    Tinocynovitis and Hand Function
• Tinocynovitis: inflammation in watertight tubes of flexor tendons 
  • Can be caused by overuse, e.g. violinists or heavy weightlifters
  • Can lead to pain, limited mobility, and sometimes locking down
  • Often treated with cortisone shots or rest, but some cases require minor surgery
• Hand function is crucial for independence 
  • One stiff finger can make the whole hand feel stiff
  • Grip strength is important for carrying things and overall strength

Grip Strength and Finger Importance

• Experiment with pull-​​ups using fewer fingers 
  • Removing the pinky finger makes pull-​​ups significantly harder
  • Brain may be protecting other fingers from too much tension
• Pinky and ring finger (under the ulnar nerve) are more important for grip strength than middle, forefinger, and thumb (under the median nerve)

Arthritis in Hands

• Two types: rheumatoid (autoimmune) and osteoarthritis (wear and tear) 
  • Rheumatoid arthritis less common due to improved medical therapy (biologics)
  • Surgery needed for significant functional limitations, usually in the hand
• Osteoarthritis has a genetic component 
  • Some people more predisposed to developing it
  • 50% of people will develop arthritis at the base of their thumb 
    • Due to biomechanics and high mobility of the thumb
    • Of those with pain, 25% may need surgery at some point
    • Surgical procedure varies depending on the stage of arthritis
      Common Hand and Wrist Issues
• Inspection is important for diagnosing hand and wrist issues 
  • Look for swelling, bulging, or resting deviations
  • Check for atrophy in three places: the thumb, the palm, and the wrist

De Quervain’s Tenosynovitis

• Swelling in the thumb area
• Inflammation of the tendons on the thumb side of the wrist

Basal Joint Arthritis

• Bulging in the base of the thumb
• Arthritis in the joint at the base of the thumb

Torn Radial Collateral Ligament

• Resting deviation of the thumb
• A tear in the ligament on the thumb side of the wrist

Tinocynovitis

• Inflammation of the tendon sheath
• Can be caused by an open injury, pinprick, insect bite, or sports equipment
• Operative urgency or emergency

Ganglion Cyst

• A lump on the wrist, most commonly on the top
• A fluid-​​filled sac that forms on a joint or tendon

Atrophy

• Loss of muscle mass, can be caused by nerve problems or muscle damage
• Check for atrophy in the thumb, palm, and wrist areas

Trigger Finger

• Inflammation of the tendon sheath in the finger
• Can cause the finger to catch or lock in a bent position
• Can be treated with cortisone injections or surgery

Boutonniere Deformity

• A deformity in which the finger cannot straighten
• Caused by the lateral bands of the tendon slipping below the axis of rotation
• Can result from a direct blow to the knuckle

Tendon Rupture

• Can occur in rock climbers due to excessive force on the tendons
• Can be caused by repeated cortisone injections in the tendon sheath

Tendon Grafts

• Using redundant tendons in the hand to repair damaged tendons
• Palmeris Longus tendon can be used as a graft in some cases

Surgical Repairs

• Basal joint reconstruction using the patient’s own tissue
• High success rate for relieving pain and restoring function
• Most common non-​​traumatic surgical repair of the hand
  Examining Hand and Wrist Injuries
• Inspect phenar muscles for atrophy or weakness 
• Check rotation, wrist, and finger motion 
  • 90 degrees of pronation and supination
  • 70–90 degrees of extension and flexion
• Check thumb motion and compare between hands
• Test strength of intrinsic muscles (ulnar and median nerves)
• Look for sprained or injured fingers 
  • Swollen, tender, and limited motion
  • Encourage movement for healing
• Examine extrinsic tendons for injuries 
  • Isolate specific tendons and nerves if needed
• Consider nerve pains and their origins 
  • Neck, brachial plexus, or specific nerves
  • Parsonage Turner syndrome: inflammation of nerves, mixed palsy, and weakness 
    • Treated with steroids, most recover completely

Diagnosing Shoulder Pain and Nerve Issues

• Shoulder pain can originate from the neck or other areas
• Intrinsic shoulder problems usually don’t cause pain below the elbow
• Numbness in multiple areas can indicate a more complex issue
• Double crush: compression of a nerve in multiple locations, causing symptoms in multiple areas
  Pinching of Nerve in the Neck
• Can be caused by a disc or phraminal osteophyte 
• Results in double crush phenomena 
  • Compression in the neck and carpal tunnel or cubital tunnel at the elbow
• Treatment may involve physical therapy, steroids, or surgery

Nerve Compressive Neuropathies and Injuries

• Can be diagnosed through electromyography and nerve conduction tests
• Poor man’s neurologic exam can also be helpful 
  • Palpate nerves in the neck, collarbone, axilla, elbow, and wrist
  • Check for numbness, tingling, and pain in specific nerve distributions

Cubital Tunnel Syndrome

• Caused by compression of the ulnar nerve at the elbow
• Can be diagnosed by palpating the nerve in the groove and checking for electrical shocks
• Treatment may involve surgery, especially for throwing athletes

Carpal Tunnel Syndrome

• Caused by compression of the median nerve at the wrist
• Most sensitive and specific test is thumb pressure directly over the transverse carpal ligament
• Other tests include tenEL signs and Phalen’s test

Musician Treatment Foundation

• Founded by the speaker almost six years ago
• Aims to help musicians with nerve injuries and other physical issues affecting their ability to play
  Dr. Attia’s Connection to Music and Medicine
• Dr. Attia’s passion for music is as strong as his passion for orthopedic surgery 
• Started his practice in New York City 
  • Inherited the care of the New York Philharmonic and Metropolitan Opera Orchestras
  • Expanded to treating Broadway musicians and various genres (jazz, rock and roll, etc.)
• Treating musicians is both stressful and rewarding 
  • Musicians are like athletes in terms of their dedication and the impact of injuries on their livelihood
  • Music is a universal language that transcends political boundaries and brings people together
  • Musicians contribute to the beauty and entertainment in the world