Amanda Wilde (Host): Shoulder pain is incredibly common and can seriously impact a patient's wellbeing. Today. We talk about treatment options that offer significant quality of life improvements with Dr. Vishal Mehta, orthopedic surgeon affiliated with Ascension Illinois. 

Welcome to “Vital Signs,” the place for Ascension Illinois physicians to trade advice, spotlight new treatments and share stories. I'm your host, Amanda Wilde. Dr. Mehta, welcome.

Vishal Mehta, MD (Guest): Thank you, Amanda. Thanks for having me.

Host: Now shoulder pain affects roughly 18 to 26% of adults in the US. I mean, that's nearly a quarter of the adult population. Why is that? Do we know?

Dr. Mehta: Yeah, there's a few reasons behind it. One is that it is simply anatomy. The shoulder is a very vulnerable joint. It provides us with a tremendous amount of flexibility. There's no joint that allows the range of motion that the shoulder does. So, in order to provide that range of motion, it has a very complex mechanism of structures holding everything in place, namely the rotator cuff.

So, the rotator cuff is a group of four tendons that keeps that shoulder balanced. It keeps the ball in the socket and because it has to provide such a large range of motion, it sees a lot of stress and has become a very common place for us to see injuries. And that combined with a population which is living longer and staying active longer, has just really caused a incredible increase in the amount of shoulder injuries and rotator cuff injuries in particular, that we see every year.

Host: What are the most common shoulder injuries you see in your practice? You mentioned rotator cuff injuries. Are those the most common?

Dr. Mehta: Yeah. By far rotator cuff injuries are the most common shoulder problem that we see. And it's really not just specific injury. It's a whole spectrum of injuries. So, what I mean by that is in the very early stages, rotator cuff problems can simply be inflammation. So, you can have a tendonitis or an inflammation of the bursa around the rotator cuff. And that's a much simpler problem to treat. Or on the other end of the spectrum, we can see full thickness rotator cuff tears, where the rotator cuff has completely torn off the bone. And typically we have to fix those back with anchors. And then we see everything in between with partial thickness tears or high-grade partial tears.

So, rotator cuff's by far the most common thing we see, but we also see a lot of other shoulder problems. We see arthritis in the shoulder which is becoming more and more common with an aging and very active population. We see what we call a frozen shoulder, which is where the capsule around the shoulder freezes, gets tight, shrinks down, and patients lose their range of motion. And that can be an incredibly painful problem. And then we see less commonly things like calcific tendonitis, which are little calcium deposits in the rotator cuff or fractures of the shoulder or tears in the cartilage bumper of the labrum. But that's really the majority of shoulder issues we see.

Host: So it sounds like the, of course, the sooner we treat these problems, the better. Any advice on how to identify shoulder issues earlier on.

Dr. Mehta: Yes. So, you're a hundred percent correct. Almost always, the earlier and the sooner we catch them and identify them and treat them, the more successful the treatment is. And the more likely we can get by with a non-surgical treatment. So, we definitely want to catch these issues soon. The best rule of thumb, and what I tell patients is you can give it a few weeks, but after a few weeks, if it's not improving, you should go see a shoulder surgeon and seek their advice. And there are some other things that should trigger you to get advice sooner. So, those things are night pain. If it's really hurting a lot at nighttime and you can't sleep, that's a sign of a bigger problem. Or if it's an issue that came on after a trauma of some sort. So, for example, if you fall down and now you have shoulder pain and you can't lift your arm anymore, that is a sign that you've torn your rotator cuff, and you should get treatment sooner rather than later. Basically, if there's significant pain, that's not getting better after a couple of weeks or is worsening, or if there's a traumatic event and now you have a loss of function, those are all reasons that you should go see a shoulder doctor sooner rather than later.

Host: And are those the same guidelines for physicians then, so that we know when to refer a patient to an orthopedic surgeon?

Dr. Mehta: For the most part, but you know, there's a lot of skilled physicians, primary care physicians, which will be comfortable managing some shoulder issues. So, for example, shoulder impingement is a very common problem that we see which is basically just inflammation around the rotator cuff. And if a primary care physician is comfortable with that diagnosis, I think it's reasonable for them to send that patient to physical therapy for a period of time. But if it's not improving after six weeks or if it's worsening or if the patient can't sleep at night, I would use that as a trigger as well, to refer to a shoulder surgeon.

Host: So, let's talk about treatments, getting relief from these injuries. What are the new treatments for the rotator cuff injuries?

Dr. Mehta: Yeah. So, it depends what the rotator cuff issue is. If it is simply inflammation around the rotator cuff or what we refer to as shoulder impingement, really, the tried and true treatment are a subacromial cortisone injection. So, an injection of cortisone around the rotator cuff and a course of physical therapy.

The addition to that, that we have seen some progress with and, and really some success with is we can now use things like platelet rich plasma, where we draw the patient's blood, spin it down, get the growth factors and inject those growth factors around the rotator cuff. So, that can be an option for patients who for whatever reason cannot tolerate or are unwilling or have failed a typical cortisone injection.

Really where we've seen a lot of advances is in the rotator cuff tears. So, now when we have a patient who has a full thickness rotator cuff tear, particularly one that is irreparable; so let's say we have somebody who's young, 40 or 50 years old, they have a large rotator cuff tear that for whatever reason hasn't been treated for years and now can no longer be repaired. Now we have some new options. We have something called a subacromial balloon spacer, which has only become FDA approved over the past several months where we can put a balloon between the humeral head and the acromion and inflate that balloon. That's something that can be done in about 20 minutes in an outpatient setting.

And now that ball, the humeral head instead of riding high is centered again, and that can help with both pain and elevation. Another similar procedure, which has become popularized over the past several years, and we are using more and more is something called a superior capsular reconstruction. Where we can put a patch of tissue, typically human skin, human dermis between the glenoid, so the socket and the humeral head. And that also helps tether that humeral head and keep it down and centered and allows patients to elevate that arm without the pain and discomfort they would have without that procedure.

Host: So, those are some exciting new developments and more tools in the toolkit. Do you start with the traditional cortisone when you end up using some of these other techniques, like subacromial balloon spacer or patches?

Dr. Mehta: Yes. Yeah, typically, we have a stepwise approach to all of this, so we never want to do things that are more aggressive than necessary. When I talk to a patient, I explain to them a whole spectrum of treatment options. And I tell them that we can start with things such as physical therapy and an injection. And then we can work our way up to these more complex surgical procedures, but that we should always start with this linear stepwise approach from more conservative to more invasive. With any of these breakthroughs, while they're exciting and there's a lot of potential, they ultimately expose the patient to some amount of risk and we do not want to expose patients to risk unless it's absolutely necessary. So, yes, we always want to start with the more conservative tried and true approaches.

Host: Okay. Got it. And what are new treatment options for osteoarthritis and is osteoarthritis sort of inevitable for us as we age?

Dr. Mehta: In a sense, yes. So, you know, the sad reality is that we are all aging and as we age, all of our joints go from being coated with nice, shiny articular cartilage in our teens and twenties. And then we start this slow degradation process, which is, it's sort of demoralizing to think about, but you know, in our thirties, forties, fifties, we sort of maintain and start to lose articular cartilage.

And then it's downhill from there. So, it really just does become a function of how long you live. And unfortunately the longer period of time you live, the more degraded those joints become, and the more inevitable osteoarthritis becomes. So, so yes is sort of inevitable and a function of aging.

Now, there are things that can advance that arthritis. So, for example, trauma can bring that arthritis on sooner. And the most common thing we see in this country is being overweight and obese and that increases that rate of arthritis.

Host: What preventative measures can we take?

Dr. Mehta: Yeah, for the shoulder, it's more complex. For, you know, for knees and hips, it's much more straightforward. You can maintain an ideal body weight, avoid impact, do things like, you know, a bicycle, elliptical and swimming instead of you know, running, jumping, squatting activities. For the shoulder, it's more complex than that.

Obviously, if you are in a position where you are doing heavy manual labor your entire life, those shoulders are probably more at risk than if you have a desk job. But those are typically not things that we can alter very much. In terms of protecting the shoulder in general, not just arthritis, but the rotator cuff, we really do want to be careful with our exercise routine. So, we want to be very cautious with any over the shoulder exercise. We want to be very cautious and really, I would suggest against any swinging of dumbbells, swinging of kettlebells, anything like that can really put a lot of stress on the shoulder.

And when you're in your teens and twenties and thirties, you can get away with it. But as you get into your forties, fifties, plus, I really discourage those activities. And you just want to always be careful when you exercise with your shoulders. So, you want to not exercise when you're fatigued, you want to exercise and use weights that you can put up 8, 10, 12, 15 times. You don't want to be putting up weights that you can only get up three or four times. It puts a lot of stress on the shoulder.

And then back to your original question about treatment options and new treatment options for shoulder arthritis, we really have a lot. And going back to that spectrum of options that I talked about, when we look at this conservative side of the spectrum, we do try things like cortisone injections. We can also, and what is approved for our older population, the Medicare population is Visco supplementation or what we call the gel shots, which is basically an anti-inflammatory and a lubrication. We use that all the time in knees, but we can use it and it is covered by Medicare in our Medicare population.

So, that's something that we frequently use in shoulders as well. And then we use things like platelet rich plasma, which I mentioned previously. And even we can use some stem cell derivatives. So, for example, bone marrow aspirate, or even adipose-derived stem cells in certain situations. So, those are all conservative options. Moving forward from that, once in a while, we can consider something smaller, like a shoulder arthroscopy where we can go in there and really just clean things up. That tends not to work very well when the arthritis is more advanced.

And then we look at things like a shoulder replacement or a reverse shoulder replacement. And that's where we've seen a ton of advances recently. So, for example, with shoulder replacements, I do at least half of my shoulder replacements as outpatients now. So, patients come in, surgery takes an hour and they go home the same day.

So, it's a much quicker recovery than it's been in the past and we can do it in a minimally invasive fashion. So, for example, I did one at the surgery center yesterday. Patient went home the same day and it doesn't even have a stem anymore. So, in the old days, I say the old days, but I mean, even nowadays, and a couple of years ago, there was a stem that went down into the humerus. Now it's just a cage that barely goes into the humerus and a ball that sits on top. So, it's really become a much less invasive procedure than it has been in the past.

And then in cases where we have advanced rotator cuff issues, we switched to something called a reverse shoulder replacement. And this is a question that I often get, when do we do a reverse shoulder replacement versus a regular shoulder replacement. And we want to do a reverse shoulder replacement in patients who do not have a reliable rotator cuff. So, if we do a regular shoulder replacement in a patient who's rotator cuff's not functioning, they will have a bad outcome and their prosthesis, their socket will loosen early. So, then we want to switch to this reverse shoulder replacement, which was something designed by the French, two or three decades ago and has been FDA approved in this country for the past 15 years and has really been a breakthrough in treatment for arthritis in the population that has rotator cuff deficiency. So, it's been a tremendous advance for us and it's becoming the majority of shoulder replacements done in this country.

Host: All patients are sort of candidates for the conservative measures. You mentioned it's a step-by-step process, like Visco supplementation and platelet rich plasma. And then we may advance to total shoulder replacement or reverse shoulder replacement. What do you see in your patients that let you know the treatment you're using is working?

Dr. Mehta: Well, we follow patients closely, so we'll do an injection and then we'll typically see them back in, three or four weeks. We ask them to keep a pain score, basically. So, we want them to record how much they have improved. And then we typically get some idea in terms of a percentage. And so some patients will say, look, I am 50% better or I am 80% better. And other patients will see very minimal improvement and we keep a close eye on that as we try these different treatment options and progress towards the shoulder replacement.

But really what we're looking for, the main thing we're looking for is a reduction in pain. And then the second thing we're looking for is improvement in function, but it's really the pain that drives people in and shoulders are notorious for hurting at nighttime and interrupting sleep cycles. And when you can't sleep well at night, it becomes really difficult to enjoy your life. So, that's the most meaningful impact that we can have upon that patient is reducing or eliminating their pain.

Host: And the emphasis of these new treatments is on ease and quality of life. And that's going to bring a lot of wellbeing on the doctor side and the patient side.

Dr. Mehta: Absolutely. Yeah. There's nothing more gratifying than taking a patient who is in constant pain and eliminating that pain. And that's the goal of all of these procedures that we're discussing.

Host: Doctor, thank you so much for this enlightening conversation and the information about shoulder issues and these new treatment options.

Dr. Mehta: My pleasure, Amanda, really nice to be with you today.

Host: This is “Vital Signs,” the podcast from Ascension Illinois. Thank you for listening – I’m Amanda Wilde. For more information, visit ascension.org/ILortho.