Dr V K Pandey Kalyani knee & shoulder Clinic

What is Rotator cuff?

Rotator cuff is a hood formed over the ball of the shoulder joint. It is formed by joining together of tendons of four muscles inside the shoulder. These muscles form the deeper layer of shoulder muscles. Their function is to stabilize the shoulder so that the other strong muscles of the shoulder can perform their function. It is only by synchronized action of the deeper (cuff muscles) and those of the strong (superficial) muscles that we are able to position our arm in so many different positions.

Why does it get torn?

There are two main reasons. One is that due to aging process, the tendons forming the cuff become weak. In such cases, just a minor trauma, or sometimes even no trauma, can cause rupture. On the other hand, the rupture could occur due to the strong force with which the muscle is pulled while trying to avoid a fall.

How does one recognizes that the cuff has ruptured?

Usually, there is acute pain and inability to lift the arm. One may just feel weak in trying to lift the arm to pick things up with the hand. An examination by a shoulder specialist, and MRI can detect the rupture for sure.

What is the treatment of rotator cuff tear?

Partial rupture has the potential to heal by itself. Full thickness tear involving a small portion may not progress if aggressive use of the shoulder is avoided. All other tears have

a tendency to progress with time, and repair is the best option. Upto a certain stage, a patient may feel only little disability, and the tear may be diagnosable only on MRI examination. After that pain on using the shoulder, pain at all the time, and weakness of the shoulder occurs. In an extreme case, one may find it difficult to lift the shoulder altogether. The healing of primarily traumatic tears is better than that of the degenerative tear(which occurred without much trauma). The sequelae of long term rotator cuff tear is joint degeneration. This causes continuous pain, and the only remedy is shoulder replacement.

What are the different methods of repairing the rotator cuff tear?

There are three methods:

Open surgery: This is a conventional technique being done for nearly half a century. It involves making a 8-10 cm cut, opening the shoulder by detaching the muscles on it, and then repairing. The disadvantages (common to any open surgery): Bigger scar, More pain, More stiffness etc.

Mini- Open Surgery: In this, most of the operation and assessment is done by looking through arthroscope. The last step of fixing the torn tendons to the bone is done by making a small cut (3-5 cm). The muscles are not detached, hence the disadvantage is not there.

Arthroscopic surgery: In this technique the whole repair is conducted Arthroscopically, through only a few small cuts. It has all the advantage s except that it may not be possible

to do a good repair in all the cases. Wherever possible, this is the method of choice these days.

What is the success rate of the operation?

If done for purely traumatic tears the success rate is nearly 95%. As the age advances, and there is a component of degeneration as the background cause, the success rate drops to 70%. In those cases, where the tear occurred without much injury, which means these are mainly degenerative tears, the repair may fail. Tear at a younger age, injury as the main cause of tear, small to medium size tear, repair done within a short time after the tear, surgical technique, and post operative physiotherapy has lot to do with achieving success in these cases. In most cases, it is possible to use the shoulder fully. You can drive the car after 3 months, and resume normal activities by 4 months.

What are the possible complications of surgery?

The possible complications are as follows:

  • Inability to achieve a good repair: This happens due to poor quality of the tendons to be repaired (due to degenerative nature of the tear), or due to inability to bring the torn edge to the bone (if the delay in repairing has been substantial). Sometimes this could be due to technical failure.
  • Failure of healing of the tendons: this is sometimes not in control of the surgeon, depends upon the condition of the case.
  • Stiffness: this happens in 30% of cases, takes 4-6 months of home physiotherapy. In some cases it may take longer.
  • Infection: this can occur in any operation, but we take due care, and the infection rate matches with the best in the world.
  • Not able to achieve optimum power back: this is due to inherent weakness of muscles due to lapsed time before repair.

How much does it cost?

The cost of surgery varies from 40 thousand to 60 thousand. You may discuss this in detail when you come for fixing the date.

How long does it take to recover?

It takes 6-8 months for the complete recovery. The arm is rested for 6 weeks in a sling. This is required for healing of the tendon to the bone. During this period the person can do all his activities, but cannot use the shoulder. In the subsequent 6 weeks, the shoulder is mobilized with support. It is after 3 months that the shoulder can be used for day to day activities. The muscle power builds up over the next 2-3 months. Most patients do well with home physiotherapy, some need supervised physiotherapy in the clinic.

For more information contact us via email or telephone: Mobile: 09554066663, 09554066664, 09554066665


Arthroscopic Repair of Recurrent Dislocation of Shoulder

Dr V K Pandey

Kalyani knee & shoulder Clinic

The shoulder joint is the most mobile joint in the body. Such mobility is possible because of the unique design of the joint- a small socket and a big ball. It is for this reason that the ball often comes out of the socket with ease. Once the shoulder dislocates the tissues keeping the ball inside the socket get ripped off. In 40 percent of cases, the tissues fall back in place and heal up once the ball is relocated. In the rest the healing does not occur. There remains a weak spot through which the ball can come out repeatedly. After the first dislocation, there are 60% chances that it will dislocate again. Once it has dislocated twice, it will definitely dislocate sometime in the future.

What are the treatment options?

Surgery is the only option to fix this problem. One may decide to live with it but this has its own fallouts. Physiotherapy alone is of no help, as it does nothing to undo the basic defect.

What if does not get operated?

The shoulder will continue to dislocate. With each dislocation shoulder becomes more unstable and consequently dislocates with minor, even day –to-day movements (even during sleep). The dislocation may happen at the wrong time. For example, while trying to hold something to avoid a fall. After sometime, the bones get damaged and the joint becomes painful.

What is done in the surgery?

The surgery consists of repairing the defect. This was done in the past by open method, in which the joint is opened through a 12 cm in front of the shoulder. There are a number of ways to correct the defect by open surgery. The operation is currently done by arthroscopic surgery.

What is arthroscopic surgery?

Arthroscopic surgery is a new technique of key-holes surgery. It is done under general anaesthesia. A thin pencil-like telescope is introduced into the shoulder from behind and the inside of the shoulder examined. Once the defect is identified, it is repaired through two more key-holes. Ultimately you have only three key holes on your shoulder and not a

10 cm cut. The advantages of arthroscopic surgery are no need to immobilize the shoulder for 4-6 weeks, no prolonged physiotherapy and almost no residual stiffness.

What is it like getting the surgery done?

You will be admitted for one day, check up done will be done for fitness for anaesthesia. In case you have any allergy or other issues, inform your doctor. The surgery is done under general anaesthesia, and takes about one hour. You will be in the operation theatre

complex for about four hours for pre and post operative care. Once you are out of anaesthesia, your arm will be in a sling and there will be dressing on your shoulder. You can start eating, walking after about 6 hours and if fit can go home the same evening. You will be given an appointment to see us after 3 days, when the dressing will be replaced with waterproof dressing. You can bath and wear regular clothes after this.

You will remain in the sling for two weeks, but can walk around freely. After two weeks, you will be able to use the hand for day-to-day activities. You can drive car after 4  weeks. Some restriction of activities will be there for 6 weeks. You can go back to normal activities including sports after about 3-6 months.

How long will I need to do physiotherapy after surgery?

Most patients do very well with a 6-8 weeks home physiotherapy programme. In this, our physiotherapist teaches the patients exercises to be done at home twice a day. Some need physiotherapy under supervision and have to visit the clinic.

How much will the surgery cost?

The surgery costs Rs. 75 thousand in general ward category. In some cases, depending upon the complexity of the operation, the cost may be higher. The cost of arthroscopic surgery is more than that of the open surgery as it requires sophisticated equipment and technical expertise. A number of imported disposable items are used in this surgery, which makes it more expensive. Open surgery costs approximately 45 thousand.

What are the chances of recurrence?

The success of operation depends upon three factors

  1. How bad the joint is to start with
  2. How accurately the repair has been done
  3. The healing potential of the patient.

Inspite of the best techniques, there is a 2-4 percent recurrence rate even in the best centres in the world. The recurrence rate is the same whether the procedure is done by open arthroscopy method. There are more chances of the shoulder getting stiff after open surgery.

In case you have any queries, you are welcome to contact us at the following number

09554066663, 09554066664, 09554066665

E-mail us at

Do’s & Don’ts for patient with Patello-Femoral pain

Kalyani knee & shoulder clinic

Dr V K Pandey

Do’s & Don’ts for patient with Patello-Femoral pain


  1. Use knee support or tapping, as advised.
  2. Wear shoes with well cushioned soles.
  3. Apply heat for symptomatic pain relief.
  4. Do regular exercises to strengthen the muscles around the joint and achieve a proper balance of various muscle groups around the knee joint.
  • Quads setting: straighten your legs and tighten both the knees together, hold for 5 seconds and then relax. Repeat this 20-25 times in one go, and 4-5 times in a day. This is an anytime anywhere exercise and can be done in sitting, lying, or even in standing position.
  • SLR: Lie down straight on a bed, bend the unaffected knee to about 90 degrees and lift the other straight up in the air till the level of the bent knee. Hold here for 5 sec and then bring the leg down. Do 3 sets of 10 repetitions twice in a day. Gradually increase upto 5 sets of 10 repetitions, twice in a day. And then start doing with weights or exercise band.
  • VMO Exercise: Cross the affected leg over the other and press down as if crushing something between the legs, hold for 5 sec and then relax. Repeat this 20-25 times. Twice in a day.


Some activities in day to day life cause excessive pressure on the knee- cap joint (Patello- Femoral Joint). This leads to further increase in pain and other symptoms. To avoid, the following precautions should be observed:

  1. Avoid squatting
  2. Avoid sitting on floor, and sitting cross- legged.
  3. Avoid stairs as much as possible
  4. Avoid footwear with more than 1 inch heel.
  5. Avoid activities like jumping, jogging, running. Walking and swimming are good and can be persued.

For more information contact us via email or telephone: Mobile: 09554066663, 09554066664, 09554066665


Patient information Series ACL Rehabilitation Protocol

Kalyani knee & shoulder clinic

Patient information Series ACL Rehabilitation Protocol

The following is your expected progress of your recovery after ACL reconstruction:

Hospitalization: 2 days

Bed rest: Only for one day, on the day of surgery. From the second day of surgery, you will be able to go to the toilet with the support of a knee brace and a walking aid.

Up & About in the house: For two weeks after surgery you will be required

to be in the house. You will be able to walk inside the house with a knee brace and a walking aid.

Brace: Your leg will be in a knee brace(leg immobilizer), from the middle of the  thigh to just above the ankle, for the first two weeks. This long brace will be used only while walking, and not while you are in bed. You will be able to  walk with a small brace with hinges, in which you can bend your knee, from third week onwards. This small brace will be needed for about 6-8 weeks.

Out of house for sitting job: From 3rd week with the help of a hinged knee


Car driving: After 4 weeks.

Normal stair climbing: In about 6 weeks.

Field work: After 6 weeks.

Jogging: After 3 months

Running: After 4 months.

Light sports: After 6 months.

Unrestricted sports: After 1 year.

Rehabilitation after ACL reconstruction involves a progressive exercise program. We will teach you the exercises on your post- op visits as per the stage of rehabilitation. You would need to do these exercises at home, yourself for 3-6 months depending on your requirements. Most patients do well with home therapy program, some need closer supervision by frequently visiting our therapist.

The following are the expected goals of recovery:

  1. To get the knee completely straight (not even slightly bent) – About 1 week
  2. To reduce knee swelling – 2 weeks, sometime aspiration of fluid from the knee may be needed to reduce the swelling.
  3. To achieve knee bending – Upto 90 degrees in 3 weeks, and full in 6-8 weeks.
  4. To build up the muscles around the knee joint – Takes upto 6 months to 1 year

Schedule of visits for Surgeon’s consultation

1st visit: Approx. 5 days after surgery, for dressing change.

2nd visit: 2weeks after surgery, for stitch removal

3rd visit: 4 weeks after surgery, monitor exercises.

4th visit: 6 weeks after surgery, monitor progress.

5th visit: 3 months after surgery.

5th visit onwards Follow-up every 3 months is recommended till 1 year post surgery.

Schedule of visits for Therapy

One visit before surgery for assessment and to understand the rehabilitation protocol. After surgery it is advisable that the therapy be done under supervision 3 times per week for the first six weeks, and then once in a week for the next six weeks.

Please note: The above information presents an approximate picture of recovery after surgery. Exact progress varies from patient to patient.

For more information contact us via email or telephone: Mobile: 09554066663, 09554066664, 09554066665


Surgical treatment of ACL deficient knee

Kalyani knee & shoulder clinic

Surgical treatment of ACL deficient knee

Dr V K Pandey

What is ACL?

ACL is short name for a ligament of the knee called Anterior Cruciate Ligament. Ligaments are tough, chord – like structures, which connect bones. There are four such ligaments in the knee- one on the inner side, one on the outer side, and two in the middle (fig-1). The two middle ligaments cross each other, and are called cruciate ligaments. Of these, the one in front is called Anterior Cruciate Ligament or ACL.

What happens if ACL is torn?

The usual history is twisting injury of the knee followed by pain and swelling. Often, a cracking sound is heard. The patient may experience that his knee moved in an odd way. X-rays are usually normal, and hence this injury is often considered a ‘minor’ sprain. The patient may feel ‘normal’ for a long time, before his knee starts feeling unstable. It is only at this stage that the ligament injury is diagnosed.

Feeling of instability of the knee prevents one from rigorous activities such as running, jumping etc. Once torn, ACL does not heal. People with low- level physical activity may be able to manage despite a ruptured ACL, but in others the knee feels weak. One may feel unsure of the knee, or the knee may give-way. Each episode of ‘giving-way’ causes further damage to the knee by rupturing the meniscus (cushions). This, in turn, causes injury to the soft caps covering the bones, the cartilage (fig-1). The natural squeal of such continuing insult to the knee is early wear and tear of the knee (osteoarthritis), which becomes a source of constant pain and swelling.

MRI is one way to confirm the diagnosis of a torn ACL. Often, it is not possible to differentiate a partial tear from complete tear. Clinical examination, followed by arthroscopic viewing, is the only sure way of diagnosing a torn ACL.

What are the different ways of treating an ACL deficient knee?

Treatment with exercises: Not all knees with torn ACL need surgery. In patients with low level of physical activity (office kind of job), treatment with physiotherapy may ‘tune’ the knee to control itself. Nearly 80% of these patients may lead a normal life, and may not feel the need to go for surgery.

Reconstruction of ACL: If a patient’s body does not adapt to a torn ACL, the only option is to make a new ligament (reconstruction). This is done by replacing the torn ligament with a substitute (graft). The graft is taken from tendons of the knee and fixed where the original ligament was (fig-2). With time, the ‘new ligament’ gets incorporated in the knee, and functions somewhat like the original ligament.

How ACL is reconstructed?

ACL reconstruction is done by two methods: open surgery or key-hole (arthroscopic) surgery. Today, arthroscopic surgery has become preferred operation. The operation consists of the following steps:

  • A diagnostic arthroscopy to confirm the diagnosis, and take stock of the damage.
  • Graft harvested from the knee.
  • Graft prepared to fit as a ligament.
  • Tunnels are drilled in the bone to pass the graft into the knee.
  • The graft is fixed at two ends.

All this is done arthroscopically (with telescope), without opening the knee. There are minimum scars (fig-3)

The technique of arthroscopic ACL reconstruction is constantly evolving. The basic differences in all the available techniques are as follows:

  1. The source of the graft: The graft may be taken from the knee-cap tendon (patellar tendon) or from the tendons at the back of the knee (Hamstring tendons).
  1. Hamstring graft (preferred) 2. Bone patella tendon Bone (BPTB) graft
  1. Single or double incision: Graft fixation at two ends can be done through two separate incisions or one incision.
  2. The fixation devices used: A host of fixation devices are used to fix the graft. These are made of metal or self dissolving plastic.

Endo – CL with Bio-screw (widely accepted worldwide)

How much does the surgery cost?

The cost of treatment varies with technique of surgery. The costs also depend on whether the surgery is done by single-incision technique, in which expensive devices are used to fix the graft. Cost may vary depending upon what additional problems (meniscus tear etc.) may be detected during the operation, or use of some special implants as may be necessary during surgery.

What are the results of ACL surgery?

ACL surgery is one of the very successful operations. But in a surgery which involves healing of tissues and creation of substitute of natural body parts, a lot depends upon a patient’s healing potential. Even in the best of hands this operation is successful in 85% of cases. In others, it may be partially successful, or may not work. In most cases, instability is controlled. However, in some, the result may be less than satisfactory.

What is the procedure of operating?

You are admitted to the hospital for one day. Some tests are conducted on you to make sure that your body if fit for anaesthesia. The operation is usually carried out under a spinal anaesthetic (an injection in your back) or sometimes under general anaesthetic.

Before Surgery, Tell us if you have had:

  • An allergy or bad reaction to antibiotics, anaesthetic drugs, or other medicines, surgical tapes or dressings.
  • Prolonged bleeding tendency or excessive bruising when injured.
  • Recent or long-term illness.
  • Psycological or psychiatric illness.
  • Excessive scar formation or poor healing of wounds after previous surgery.

Before undergoing surgery you may be prescribed medication. Give us a list of ALL medicines that you are taking or have recently taken, as there may be cross reaction between medicines.

On the day of surgery, You may have to keep fasting for 4-6 hours before surgery. The operation takes about 45 min+/- 15 minutes, but you will be in a operation theatre complex for nearly 4 hours.

After surgery, nurses observe your recovery to make sure that your blood pressure, pulse, other vital signs, and the operated site are normal. In the recovery ward, you may have a bandage or temporary brace on your knee.

Care after surgery: You will be advised regarding the following:

  • Application of ice packs for 20 minutes four times daily for the first few days.
  • The use of crutches and occasionally a knee brace for a variable period
  • Medication to relieve pain and discomfort.
  • Antibiotics to reduce the risk of infection.

You will be sent home next day after surgery, and rest of the treatment will be at home. Depending on the type and extent of the surgery, you will be advised when you can resume your normal activities. An approximate recovery schedule is as shown in table-1. The time needed for the heeling of the grafted tendon may be six months or more. You may have to wait up to 12 months before returning to sports. Heavy manual work, lifting and strenuous exercise may be restricted for longer period.

Follow-up appointment: Two or more follow-up appointments will be necessary every 2-weekly, depending upon your case.

Physiotherapy and long-term follow-up: A physiotherapy and home- exercise program is important to achieve a successful outcome. Follow it carefully.

Physiotherapy and exercise assist in restoring blood supply to the reconstructed ligament. Most recovery takes place in the first six months, with range of motion and strength continuing to improve. Be careful that you do not stress your knee during rehabilitation even if progress appears to be ahead of schedule and the knee feels strong. Often a year or more of rehabilitation is needed for the knee to feel strong with a good range of movement.

All this is a part of the healing process, and differs from patient to patient. This can not be inferred as something lacking in the operation. With perseverance and additional help and

time, most of these problems get resolved, but in some cases a second operation may be necessary.

The possible complications of ACL reconstruction

Surgery to reconstruct the ACL is safe and effective. But like all operations, does have risks despite the highest standards of surgical practice. It is not usual for a doctor to outline every possible side effect or rare complication. However, it is important that you have enough information about common complications. The following possible complications are listed to inform and not to alarm.

General risks of surgery

  • Wound infection; treatment with antibiotics for long period may be needed.
  • Haemotma (an accumulation of blood inside the knee and around the surgical site) may need aspiration under local anaesthesia.
  • Slow or poor healing (most likely in smokers, people with diabetes, and in elderly people).
  • Risks of anaesthesia: Anaesthesia techniques have become fairly safe now, but an odd patient still runs the risk.

Specific risks of ACL surgery

  • The graft may fail to revascularise, and may not give the desired strength.
  • Injury to a minor nerve around the knee may produce a small patch of anaesthetic skin. It mostly recovers over a period of time.
  • Persistent low-grade pain in front of the knee occurs in about one out of ten patients, compliance with the physiotherapy program usually helps to control it.
  • Persistent joint effusion, a varied response to healing may occur, usually resolves with time or may need aspiration.
  • Terminal loss of knee motion occurs in about five out of 100 patients, usually responds to prolonged physiotherapy, may need manipulation.

Report to your surgeon: Tell your surgeon at once if you develop any of the following:

  • Temperature higher than 100 degree F or associated with chills.
  • Severe or persistent pain, tenderness or increased swelling in the knee or calf.
  • Continued discoloured drainage and bleeding from the arthroscopy wounds.

We encourage you to clear all doubts before you decide to undergo surgery. You may like to learn more about the operation from the net. We also encourage you to meet other patients who have undergone similar operation. Assuring you of best care, we wish you a speedy recovery.

For more information, Kindly contact: 09554066663, 09554066664, 09554066665 E-mail: