Find the source of your pain and get back in the game.
The shoulder joint is a complex combination of bones, muscles, tendons and tissue that is capable of a wide range of motion. When it is working properly, it allows us to raise our hand in class, brush our hair, put on a coat, reach an item on the top shelf at the market, give a hug and many more activities we don’t appreciate until pain gets in the way. The shoulder is also a key component to achievement in a number of sports. In fact, it’s hard to find a sport or activity where it’s not important to have our shoulders in good working order…think golf, tennis, swimming, football, basketball, baseball and softball, to mention just a few. Needless to say, when a shoulder is not functioning properly, or is causing pain, it’s hard to ignore.
Well-Being spoke with three orthopaedic surgeons to learn which shoulder conditions are most common, how they may be treated, and what we all should know to protect and keep this hard-working joint in good shape. Providing their expertise and insight for this article are James Randall (Randy) Ramsey, M.D., of Mississippi Sports Medicine and Orthopaedic Center, David J. Gandy, M.D., of Jackson Ortho-paedic Clinic and William (Will) O. McCraney, M.D., of Capital Orthopaedic and Sports Medicine Center.
According to Dr. Ramsey, some of the most common injuries and conditions of the shoulder he sees are rotator cuff tendinitis, rotator cuff tears, bursitis, adhesive capsulitis (or frozen shoulder), cartilage tears and osteoarthritis.
“When a patient presents with shoulder pain the first thing we do is get a thorough medical history,” Dr. Ramsey explains. “We need to find out when and how the pain started, if it is constant or occurs only during or after certain activities, and how severe it is. We also will conduct a physical exam of the area to look for abnormalities, swelling, muscle weakness and tender areas, and we observe the patient’s range of motion and strength.”
For a closer look at what is going on in the shoulder structure, Dr. Ramsey orders an x-ray or series of x-rays to check for damage from an injury or overuse.
The First Line of Defense Against Shoulder Pain
“We usually start with a conservative approach, recommending that the patient take over-the-counter anti-inflammatory medications for five days and keep the shoulder moving,” Dr. Ramsey continues. “If that fails, we might start prescription NSAIDs, oral steroids, Cortizone injections and physical therapy (either patient-guided exercises they can do at home or with a licensed physical therapist). About 80% of shoulder conditions will clear up with one or more of these treatments.”
Dr. Gandy also stresses the importance of the physical exam to getting to the source of shoulder pain and discomfort.
“Even before we order an x-ray, we can get clues about the problem by asking the patient to describe their symptoms in detail,” says Dr. Gandy. “Did pain come on gradually or did it result from a traumatic injury? Is there a catching, popping or snapping sound when the arm/shoulder is in motion? We look at the patient’s range of motion, both up and down and sideways and check to see if the shoulder joint seems loose. Then the x-ray helps us look for indications of arthritis, bone fragments, and bone spurs.”
“A shoulder can get stiff very quickly if you don’t use it. It can freeze up in just a few days, a serious condition that can even happen to young people. So it’s really crucial to get relief from pain and keep that shoulder moving. Physical therapy can play a big part in strengthening the shoulder and improving range of motion,” Dr. Gandy adds.
Topical Medications Some orthopaedic specialists also prescribe topical treatments, such as those prepared at compounding pharmacies to give relief for patients between steroid injections and for those patients who are not candidates for surgical treatments due to their age or other medical conditions.*
*Compounding pharmacies, such as Keystone Pharmacy in Madison, prepare personalized medications based on a practitioner’s prescription in which individual ingredients are mixed together in the exact strength and dosage required by the patient.
Arthroscopy While the vast majority of shoulder problems can be diagnosed with medical history, physical exam and an x-ray, when the source is not apparent after these measures, the next step is an MRI scan. If the MRI indicates problems such as rotator cuff tendinitis, rotator cuff tears, cartilage tears, labral tears or a frozen shoulder, arthroscopy can be used to get a better look at the shoulder. “The biggest reason for rotator cuff problems is weakness,” explains Dr. McCraney. “Exercises designed to strengthen the rotator cuff can often solve the problem without the need for arthroscopy.” An arthroscopy allows the surgeon to look inside the joint with a fiber-optic camera. It may show soft tissue injuries that are not apparent from the physical examination, x-rays, and other tests. In addition to helping find the cause of pain, arthroscopy may be used to correct the problem. It is usually conducted as an outpatient procedure, is minimally invasive, requires two weeks to a month in a sling, and around eight weeks of physical therapy.
Shoulder Replacement Surgery When a patient is suffering from severe arthritis, an arthroscopy is usually not recommended because the benefit of the procedure is likely to last only a couple of years. A full shoulder replacement relieves the source of pain and offers the patient the opportunity to return the shoulder to normal activity. Although shoulder joint replacement is less common than knee or hip replacement, it is just as successful in relieving joint pain.
Shoulder replacement surgery should be considered if the pain is interfering with everyday activities, such as dressing, toileting, washing, and reaching into a cabinet. It also could be an option if there is moderate to severe pain while resting and if there is loss of motion and/or weakness in the shoulder. Avoiding activity due to pain and being unable to get a good night’s sleep, can lead to physical inactivity and other potential health risks.
Reverse Shoulder Replacement According to Dr. McCraney, the biggest game changer in recent years for patients with large rotator cuff tears and other conditions who haven’t benefitted from previous treatments is a procedure called reverse total shoulder replacement. Reverse total shoulder replacement may be recommended if you have a completely torn rotator cuff that cannot be repaired, have cuff tear arthropathy, if a previous shoulder replacement was unsuccessful and other treatments haven’t worked to relieve pain and restore function.
“A conventional shoulder replacement mimics the normal structure of the shoulder,” notes Dr. McCraney. “A plastic “cup” is fitted into the shoulder socket and a metal “ball” is attached to the top of the upper arm bone. In a reverse total shoulder replacement, the socket and metal ball are switched. The metal ball is fixed to the socket and the plastic cup is fixed to the upper end of the upper arm bone. A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles to move the arm.”
Injury Prevention “Jumping into a new exercise routine or trying a new sport without giving yourself time to build strength and endurance over time, especially if you have been inactive for a while, are probably the most common reasons for shoulder injury, outside of organized sports,” Dr. McCraney continues.
“The key is, if you are having shoulder pain and conservative treatments, such as taking OTC anti-inflammatory medications aren’t working, ask your primary care doctor to refer you to an orthopaedic specialist. The longer you wait the more damage you could be doing to your shoulder joint,” adds Dr. Ramsey. “And I can’t stress enough, parents of kids that are playing one sport all year, especially softball and baseball, that is asking for trouble. Kids can get serious injuries because their growth plates are not yet complete. Even pro athletes take breaks after a season. It’s important for young athletes to have downtime too, so their bodies can heal.”
James Randall Ramsey, M.D., received his Doctor of Medicine degree from the University of Mississippi Medical Center. His training in Orthopaedic surgery incudes a transitional internship and orthopaedic surgery residency at the University of Arkansas for Medical Science. and a sports medicine fellowship with the Tennessee Orthopaedic Alliance/The Lipscomb Clinic in Nashville. He is Board Certified in Orthopaedic Surgery, and holds an American Board of Orthopaedic Sugery Subspeciality Certification in Orthopaedic Sports Medicine.
David J. Gandy, M.D., received his Doctor of Medicine degree from the University of Mississippi School of Medicine. He served his residency in orthopaedic surgery at the Greenville Hospital System and completed a fellowship in pediatric orthopaedics at Shriners Hospital (both in Greenville, South Carolina). Dr. Gandy is a Board Certified Orthopaedic Surgeon and treats both adult and pediatric patients.
William O. McCraney, M.D., received his Doctor of Medicine degree and served his residency in Orthopaedic Surgery at the University of Mississippi. While still a resident he did his AO/ASIF Trauma fellowship training under Dr. Scharplatz and Dr. Bruno Noesberger, in Switzerland and then completed a hand and upper extremity fellowship at UMMC under Dr. W. Geissler. Dr. McCraney is Board Certified by the American Board of Orthopaedic Surgery.