HHC: How to Prevent Shoulder Pain?
Hello my name is Dr. David Martin. I’m a shoulder surgeon, an orthopaedic surgeon, and I practice at St. Vincent’s Medical Center in the Department of Orthopedic Surgery. I’m going to present to you a discussion of shoulder arthritis and shoulder replacement surgery. I’m going to break it down for you and talk to you about some of the newer technologies that are available and try to educate you on shoulder anatomy and shoulder replacement and then I’d also like to break it down into how we typically come up with these diagnoses, how we evaluate patients, how we come up with treatment plans and also discuss with different types of imaging. And then, I’d like to move on to actually take you through which shoulders replacement surgery is all about and how it happens, and then open it up to questions.
St. Vincent’s Medical Center recently has been acquired by Hartford HealthCare and we’ve got some new exciting things that are going on at the hospital. We’re actually dedicating a large portion of our hospital to orthopaedic surgery including joint replacements, shoulder, hips and knees and spine surgery. First, let me take you through the anatomy of the shoulder. The shoulder is a ball-and-socket, very similar to the hip. The thing about the shoulder though is that you do have a tremendous amount more motion than the hip and that’s primarily because there’s a lot more freedom of motion to the socket. So, basically the shoulder is a ball-and-socket. The armed portion of the shoulder is called the humerus and on top of the humerus is a ball or like an ice cream cone. That ice cream cone is covered with cartilage and the socket is called the glenoid. The glenoid is also covered with cartilage and the nice thing about cartilage is cartilage gives you a very friction free interaction that allows smooth gliding and sliding in motion. So that way, the muscles that work around the shoulder don’t really have to work all that hard. So the glenoid is part of the scapula, which is also part of your shoulder blade, okay, and the bones above it, the collarbone, the clavicle, and the bone it articulates with is the acromion which is also a part of the shoulder blade. The surrounding muscles in the shoulder are primarily the rotator cuff. The rotator cuff consists of four muscles and tendons. The ends of muscles are called tendons and they consist of subscapularis, which is the front of the rotator cuff, the supraspinatus, the infraspinatus and the teres minor and together the circumferentially go around the rotator of the ball and socket and they stabilize the ball within the socket.
There are many conditions that can affect the shoulder. One of them is arthritis. Arthritis basically refers to several conditions and diseases that can lead to deterioration of the shoulder cartilage and these are classically characterized by pain, stiffness, and inflammation. Classic arthritis and osteoarthritis, which is basically age-related arthritis that people get as they get older are other diseases that can lead to arthritis in the shoulder joint. These include metabolic problems such as gout, inflammatory problems such as rheumatoid arthritis. Post-traumatic arthritis can also happen from a trauma to the shoulder joint and there’s other arthritic problems that can also result from tears and problems in the rotator rotator cuff.
Rotator cuff arthropathy is a problem that starts initially with a rotator cuff tear. As I spoke earlier, the rotator cuff keeps the ball centered within the socket. When you lose that ability to center the ball within the socket, the humerus (the ball) tends to go north articulate on the acromion, the bone that’s just over there on the tip of the shoulder. When this happens, at least an abnormal motion, an abnormal wear, within the shoulder, the result is what we call rotator cuff arthropathy. I use the analogy of your front end of your car being out of alignment when you get abnormal wear on your tires. The same thing can happen in your shoulder joint. You can develop a severe arthritis in the shoulder and this is referred to as rotator cuff arthropathy.
Other conditions that can affect the shoulder are a result of trauma. As you get older, as you age, there’s a condition called osteoporosis. Osteoporosis is basically a progressive weakening of the bone that happens, that takes place as you age. The bone density in your arm, or on any bone really, can decrease and become much more susceptible to fracture.
So when you fracture, you break the bone. You can fracture the shoulder, just the way you can fracture any other joint or bone within your body. When the joint becomes undone and the ball comes out of the socket, we refer to that as a dislocation which could also happen. Some dislocations can occur without fractures. Some dislocations occur with fractures. You can see the illustration here that this is a pretty severe fracture. It’s characterized by a very broken up humerus bone and the fall from the humerus is actually dislocated out of the socket.
Today, one of the more common joint replacement surgery is shoulder replacement. Behind hips and knees, it’s the third most common joint replacement. It has its actual origin back in about 1890. This was done in France and this was a procedure that was initially done by a French surgeon named Emil Keon, who did it for tuberculosis in the shoulder. That’s our first noted major joint replacement and it really was not improved upon until the 1950s when a famous American surgeon named Charles Near, developed the anatomic shoulder. The anatomic shoulder is a shoulder replacement in which we replace the shoulder joint anatomically. We take out the arthritic portions of the joint and we replace it with a combination of metal and plastic. What you need for a proper functioning anatomic shoulder is a rotator cuff so even though in the scheme that we have presented, there is no rotator cuff listed or illustrated but there typically is a rotator cuff that goes around the ball and socket and maintains the ball within the socket. When you have a partial shoulder replacement where you just replace the ball portion that’s called a hemiarthroplasty. When you replace not only the ball portion but you also replace the socket, that’s called a complete or total shoulder replacement another word for replacement the reverse shoulder replacement shoulder replacement. Another word for replacement, or joint replacement, it arthroplasty.
The reverse shoulder replacement is a shoulder replacement is a shoulder replacement that was also developed in France. It was developed by a famous French surgeon in Paul Grammot and he basically started doing the surgeries in the 1980s and it was pretty much developed in Europe and finally became available in the United States and FDA approved in the United States in 2004. Now the thing with the reverse shoulder is now it is actually more common and more frequent to have a shoulder replacement done with the reverse shoulder than the anatomic shoulder. You need a very good functioning rotator cuff for an anatomic shoulder to operate properly, to work properly. The reverse shoulder compensates for this by actually reversing the components and the ball, this time, is actually secured to the scapula, to the glenoid, and the socket is now on the humerus.
So, what’s happening is you’re resisting the shear of the deltoid by the ball and the socket being in an inverse relationship and that allows very reasonable function. It’s not a completely normal shoulder by any means and it still has some limitations, but it’s an outstanding procedure for pain relief and it does allow for significantly improved function than what the patient had prior.
Now that you have a technical understanding of shoulder replacement, I think that it’s important to understand how the whole process starts. I’m a shoulder surgeon and I see patients that come to me for shoulder problems and typically they come and they may not even know what their diagnosis is, rather, they just know that they have pain and they have a problem. So what we do is we start off by taking a history, we talk to the patient, what the problem is. Sometimes it turns out it’s not the shoulder, sometimes it’s a problem they they’re having in another part of their body that’s referred as shoulder pain. For example, a classic presentation is someone who has a problem in their neck and they’re feeling the pain radiating from the neck into the shoulder, a pinched nerve essentially, so it’s very, very important to keep all of this in mind and you have to, sort of, keep the whole patient and the whole problem in perspective. So, we start off with the history, we then perform a physical examination. We also will frequently at the time of the initial consultation do other imaging studies, such as x-ray, and we formulate a diagnosis and the purpose of today’s talk is to actually talk about shoulder arthritis and when we do shoulder replacement surgery. So, I want you to understand that there are problems that we do diagnosis patients with. This could be a rotator cuff problem, it could be a different type of bone spur, it could be another type of arthritis, maybe your acromioclavicular joint. So, there’s a number of things that we could potentially come away with, and diagnose the patient with, and formulate a treatment plan.
The treatment for typical arthritis is initially, it’s maybe an anti-inflammatory medicine, maybe some medicines such as Tylenol. Maybe some ice and stretching, some very conservative things. Oftentimes by the time patients have seen me, they’ve often provide these things. Sometimes we’ll move on at the initial consultation, maybe we’ll try a cortisone injection, a cortical steroid injection. There are other things that can be injected as well. Hyaluronic acid, which is a jelly that we sometimes will inject into the shoulder joint to help decrease the friction, that’s a possibility, but what we come off of the consultation with is essentially a treatment plan and that could conclude further diagnostic testing.
This is an x-ray of a right shoulder. This is typically our first diagnostic test, which is obtained in the office. In this case, this is a, what we call an anterior, posterior view with the right shoulder and this shows the humerus of the shoulder with the ball and the socket or the glenoid and you can see from this x-ray that there is a very large bone spur or osteophyte down here on the inferior march of the shoulder. You can also see that there’s diffuse narrowing of the shoulder joint consistent with osteoarthritis, and from this x-ray alone, and also the maybe some additional views that we might obtain in the office, I can tell the patient what their diagnosis is, osteoarthritis, and we can formulate a treatment plan.
Further diagnostic testing is sometimes necessary and this is especially necessary for planning any aggressive surgeries such as a shoulder replacement. This is a CAT scan. This CAT scan allows very detailed imaging, especially a bone. It’s a great way to image bone and it’s a great way to really see deformity. You can see in this case that the shoulder, as a ball-and-socket, the ball and the socket you see the specific amount of deformity that’s within the socket so this is something that would need to be addressed and taken into account when surgery is performed.
This is an MRI. The MRI is a fancy test that uses very detailed imaging of not only the shoulder but also the surrounding soft tissues.
For practical purposes, the CAT scan, the CT scan gives you more bony detail but the MRI actually can tell you the status of the rotator cuff, the status of the soft tissues that are circumferentially around the shoulder. So the MRI can be a very valuable test in conjunction with a CT scan and the x-ray diagnosing somebody with shoulder arthritis and coming up with a preoperative plan. Once we decided that surgery, joint replacement surgery, is appropriate, a preoperative medical evaluation is almost always required. We do this to make sure that the patient is in optimum medical condition for the surgery and we can get through the surgery with minimal complication.
Sometimes, for example, patients that they have underlying problem that they are aware of or even unaware of, for example, diabetes. It is important that you have optimal diabetic control and there are ways in which the primary care physicians can optimize this and allow us to get through our surgery with minimal complication and morbidity to the patient.
One of the things that we offer our patients before surgery is a preoperative class. We currently do this for all of our hip and knee replacement surgeries that get done at St. Vincent’s, but now we’re also introducing this and offering this to our total shoulder replacement patients. And what this basically does is it gives you an opportunity to come in, see other patients who are going to be going through the same process and speak with providers about the care that’s offered and what their expectations should be during their stay at the hospital.
This is a picture of our galleria that’s part of our St. Vincent’s Medical Center and it’s an area in the hospital just adjacent to the operating room where you can wait for your your family member or loved one while they have surgery and it’s also an area where the surgeon/the doctor can come out and speak with the family soon after the surgery.
Anesthesia. Everybody always wonders about anesthesia and it’s extremely important, obviously, we can’t do the surgery without it. There are two types of anesthesia. There’s what we call general anesthesia, which is you go to sleep and you wake up and your surgery’s over and everything’s done and you move on.
And then there’s regional anesthesia. The regional anesthesia that we use for shoulder replacement surgery is an inter scalene anesthetic, so basically there’s a needle that is inserted by the anesthesiologist above your shoulder and that numbs your entire shoulder and it even numbs your arm, your forearm, and your hand. The beauty of that, is that you have no pain when you have the surgery and you wake up and there’s no pain. The other nice thing is that we have these very long-acting anesthetics now so that you can get between 24 and 48 hours of pain relief from the regional block from the inter scalene anesthetic. So what we typically do with our shoulder replacement surgery is a combination of both. We use both the inner scalene, which again, allows for a significant amount of pain relief postoperatively but we also use general anesthetics. Essentially, you go to sleep. The surgical time for a shoulder replacement is typically from 1 to typically 2 hours at the most. It’s really not that long a period that you’re asleep and again, it’s using a combination of both general and regional anesthetic and I think that gives you the best of both worlds.
The actual surgery is done in the following fashion I’m going to try to illustrate this for you. Our surgery starts with general anesthetic, which we talked about. We use a standard delta to a pectoral approach to the shoulders, so an incision in the front of the shoulder. We go through the muscles, the deltoid and the pectoralis, and we cut the subscapularis tendon, then we open the shoulder and we expose the glenoid. We also remove the proximal portion of the humerus and that we prepare the glenoid to accept the socket. Then, we prepare the humerus. The humerus is here shown cut across the proximal humerus and the metal prosthesis is inserted and the shoulder is then put back together, relocated, and the rotator cuff, the subscapularis in the front is then repaired. We then close the surgical incision. In my closures, I typically use what’s called subcaticular closure with a glue that is applied over the skin so that there are no staples to remove
Postoperatively, there are good number of people that we actually do as outpatients, we actually send home the same day. The reason we can do that is we have such great anesthetic with those long-acting anesthetic blocks that you can actually go home very, very comfortably and you might as well go home if you’re comfortable.
The blood loss is typically not that much, so we don’t, typically, have to, extremely very rarely do we have to give anybody blood products or transfusions postoperatively. So, we typically will send you home that day, or the latest, typically one day later. Patients do wear a shoulder immobilizer and typically, they lower the shoulder immobilizer for anywhere from two to four weeks.
The reverse shoulders, we are a little bit more aggressive allowing early range of motion and get patients using the shoulder fairly quickly. I do allow patients to use keyboards, I allow patients to use their right hand or feeding themselves or some light grooming, but again, the shoulder immobilizer is worn for about -anywhere up to maybe four weeks. You will receive during this period, you will start formal physical therapy and typically therapy is required for up to about three months or so.
Most people are back to most of their typical activities by three months and usually full unrestricted activities at 6 months. There are certain activities that I tell people to refrain from. It’s usually not a problem, but I tell people to refrain from martial arts or powerlifting, but there are activities such as golf and tennis which I think are perfectly reasonable to resume.
Complications can happen in any type of surgery. One of the complications that we always talk about, that we always think about are infection. We take all types of precautions to prevent infection but they do happen. They’re pretty rare within shoulder surgery, but they can happen. Sometimes they require further surgery and even intravenous antibiotics to clean up or clear the infection.
Nerve and blood vessel injury, that can happen, again it’s pretty rare. Typically when they do happen it’s a nerve injury that’s from a stretch and a stretch injury typically does resolve on its own.
Other complications, loosening of the components, okay, the components that we put in could potentially loosen, again not usual. It doesn’t typically happen. It can happen with time, for example, the socket portion of a total shoulder arthroplasty can loosen the glenoid but that typically requires many, many years to happen, but again, it can happen.
Fractures. You can fracture around the components that we insert. That could happen in the operating room and can also happen if you have a fall at home. You can fracture around the tip of the prosthesis. You can fracture around the socket.
Dislocations. Dislocations can also happen. I know, again, very unusual for that to happen but it can happen where the ball comes undone from the socket and that could require further surgery or at least anesthetic to relocate the components.
Shoulder replacement surgery is a life-changing experience and it offers some great improvements in your life and your lifestyle. It offers great pain relief and offers great improvements and function.
The vast majority of the surgeries are performed with very minimal complication and the vast majority of patients are extremely happy that they went through it and had it done. It’s a procedure that I love to do and I love taking care of patients with arthritis in the shoulder. This concludes my presentation and I’d like to open it up to questions.
Jeff: “Hi Dr.Martin. My name is Jeff, I’m a little nervous like everybody else. How soon after surgery can I get my life back in regards to driving and working around the house, you know, normal activities?”
Dr. Martin: “Typically I encourage people to do certain normal activities immediately after surgery. I like to get people moving their hand and their elbow. So for example, if you like to play with your computer, your laptop, your phone, I encourage that and I also encourage use of the hand, bringing your hand to your face for example to feed yourself I think is all great. Again, we talked about the sling. It’s usually two to four weeks in a sling and by about six weeks or so, I will let people start driving and being more aggressive in physical therapy. It’s important early on to protect and especially in the anatomical shoulders, we had to prepare the subscapularis so in this first six weeks or so, you want to be very, very careful and not over do it because you don’t want to disrupt that repair so you have to be very very careful and again by about three to four months after surgery, people are doing most things that they do. Maybe not playing tennis, maybe not playing golf, but most things that they typically do at their homes: cleaning, vacuuming, laundry, shopping, they’re doing that by then.”
Jeff: “Thank you. I have a follow-up question. My friend, she had staples when she had a total joint and hated the feeling. Are there any alternatives to staples?”
Dr.Martin: “Yeah. About 2 years ago or so I switched from using staples to a resorb-able stitch that we put under the skin. It takes extra time to do this and I’ve been extremely pleased I’ve been very, very happy. We’ve also put in a little bit of a say it’s a glue. It’s a skin glue that we put over so it seals everything off very nice and so there’s really nothing to take out and we’d be using a very small waterproof dressing directly over the surgical incision and the other nice thing about that is it allows you to shower, really, when you’re comfortable you can start showering because it’s waterproof and we typically will take that dressing off in about a week or maybe up to ten days and there’s really nothing further to do regarding the incision so, again, that’s been sort of a game changer and I’m very, very pleased the way the surgical incisions have been healing.”
Prospective Candidate: “Hi doctor. I’d like to know how much pain should I expect to experience after surgery and also wanted to know if there’s a difference in how a reverse versus an anatomic shoulder feels?”
Dr. Martin: “The good news is we have much, much better ways of managing pain now than we ever did. I’m a big believer in understanding a lot, which I’ve talked to you about earlier in the presentation and they’ve had this new medication come out, it’s called a liposomal marking and what that is, is a very long-acting anesthetic. So, what happens is you can get significant pain relief for a good 48 hours or so. The nice thing about it is that you have that, unlike when you wake up from general anesthetic and you have no pain relief and then it’s just severe, the anesthetic just sort of gradually wears off. So, I think patients have been very, very please with it. We sometimes do require some additional medications to be taken by mouth to help and assist with the pain relief but we’re using far less of that today than we ever did and obviously with the concerns of opiate use, we try to really minimize that today and again, I’ve been very, very pleased the way that’s been going and I think most people, when you ask them in retrospect, they’re quite pleased and the pain associated with this is not necessarily a major thing that they focus on.
As far as the difference between how patients feel and function after a anatomic shoulder versus a reverse shoulder, the thing with the anatomic shoulder is, it is anatomic, so it actually feels more natural, okay, it’s basically more natural and said if there’s a little bit more physical therapy involved because you got to retrain your muscles to, especially the rotator cuff muscles, to start to function once again and function properly, but patients with an anatomic total shoulder tend to feel, and actually, usually do have better function. The reverse shoulders, they recover quicker but they do have some limitations. Typically they have some, it’s not a completely normal feeling shoulder, the ways maybe some of the anatomic shoulder people talk about it. So, for example, patients with a reverse shoulder will often describe some difficulty rotating their arm in space. So, for example, reaching up into your cabinet, if you go for one box of cereal and you decide that’s the wrong box and you got to move your arm or your hands over to the other box, the one that you wanted, rather than rotate, some people with a reverse shoulder will say they actually have to move their whole body. They can still get the arm up but they, the problem is more or less rotating so it’s a little different prosthesis and, again, both are excellent for pain relief and I think most people are very, very happy and pleased that they’ve had it, at least my experience.”
Sue: “Hi Dr.Martin, my name is Sue, thanks for taking my question. My question is how does a patient know if they’re ready for shoulder surgery? Like I’ve been having awful shoulder pain and they told me that I’m a candidate for shoulder replacement. But I don’t feel like I’m quite ready. Is there any alternatives besides physical therapy and steroid injections that I can consider?”
Dr.Martin: “Well sure, there are other treatments for shoulder arthritis. One of the treatments would be hyaluronic acid, which is more and more people are using than that. It’s something that it’s a jelly that was initially approved for the knee where you basically inject it. It’s kind of like a three in one oil that we inject and we will use it for the shoulder on certain occasions. That kind of gives us extra lubrication. There are other treatments/injections that can be tried. There are stem-cells, some people refer to them as stem-cells, but the big one is a thing called PRP which is platelet-rich plasma. That’s where we take your blood and we spin out the platelet layer and then we inject that. That’s not exactly stem cells, that’s really a blood product and again, if this is all what we’d call off-label or not really approved, it’s sort of what we call experimental but there have been some studies that suggest that PRP can help with arthritic conditions and different joints, including thew shoulder, hip, knee, so that’s a possibility.
Other surgeries can also be considered if your arthritis is not too bad, you know, some people do benefit from an arthroscopy, which is where we go in through tiny little puncture holes and kind of, and again, this is done under anesthesia, it’s done in the operating room and we just kind of go in there and kind if clean out a lot of the debris that’s formed. It’s kind of like, I always tell people, it’s kind of like when you go in and your brake shoes are just kind of all worn down and there’s all kinds of stuff that’s built up, you just kind of go in there and clean all that stuff off and hopefully get a little better function, maybe less mechanical symptom, some pain relief, but yeah there are other things other than shoulder replacement but as far as when to consider a shoulder replacement, I think that’s when it’s a pretty moderate to severe arthritis and it’s just ruining your life. Some people just can’t sleep, some people just can’t function, some people lose the ability to maintain their independence, abuse somebody who maybe lives alone and you can no longer care for yourself and maybe a joint replacement or a shoulder replacement is right for you.”
Christian: “Hey doctor, my name is Christian and I just wanted to ask if there is any sort of age threshold for getting this type of surgery?”
Dr. Martin: “Yeah, well that’s a great question and some people think that maybe they’re too young. Some people maybe think that you’re too old and it’s all very, very relative. Years ago, we used to try to do joint replacement surgery and people on people who are older, for example, when the reverse shoulder first started/first came out, it was recommended to refrain from anybody under 70 and we still try to, to some extent, we still try to do reverse shoulder in somebody who’s older, maybe 60s, 70ish. The anatomic shoulders we’re doing younger and younger people, I mean there’s higher demands. There’s a lot of powerlifting and a lot of things that patients have kind of worn out their shoulders and you’re in debilitating pain and there’s no cartilage left. We’re doing more and more anatomic shoulders on younger people. That’s just the way it is and as far as an upper age limit, well, there’s really not. I mean you know, everybody’s different, I mean, there are people who are in their 65-70 years old who also physiologically a lot older than that and then there are people 80 years old and physiologically look 60-65 years old and are very high demand, so there really is no upper limit on age. I’ve had done shoulder replacement surgery on people in their 40’s and I’ve done shoulder replacement surgery on people in their 90’s. So, there’s a big spectrum and it really depends on what the needs of the patients are and what the expectations of the patients are.”
Vinny: “Hello doctor, my name is Vinny. I have a question. I’m afraid of staying overnight in the hospital. Do I really have to?”
Dr. Martin: “Well no, actually, you do not have to stay overnight in the hospital. We’ve modified our surgery so much between the blocks that we use, the long-acting blocks, which give a great pain relief, so typically you wake up and you’re not having any pain. An overnight stay is not typically necessary especially if you’re in reasonable medical help. Now if you have many medical issues and you may require some monitoring, you may require, for example, if you had maybe a heart problem in the past, if you’ve had a heart attack, they may want to keep you overnight and check an electrocardiogram or have your cardiologist see in the next day, that’s a possibility, but no, I would say that the majority of what we do as shoulder replacement can be done as an outpatient, especially somebody who’s maybe a little bit younger, active, and healthier. The other thing that we use is we use a medication called transcendent acid which helps reduce blood loss, so it’s extremely rare today to require any type of blood transfusion after a shoulder replacement surgery. It still potentially could happen, but there’s a number of reasons we’re now able to do this outpatient similar to what we’ve done by the way in other joints I mean, for example, hips and knees are also moving to being done as completely outpatient where you can get to basically go home and spend the first night in your own bed which is a great way to do it if you can.”
Well, if there’s no more questions, I’d like to thank you for attending my webinar and I wish you well and I hope we were able to provide you some information that may help you make great decisions in the future. Thanks again, my name is Dr. David Martin.