Transcription:
Shoulder Pain

Melanie Cole (Host): The shoulder is the most biomechanically complex joint in the body and if you have shoulder pain and it’s limiting your daily activities, there are a variety of interventions, surgical and nonsurgical available. My guest is Dr. Benjamin Lindbloom. He’s an orthopedic surgeon with Baycare Health. Dr. Lindbloom, as I said in my intro about how biomechanically complex it is, tell us a little bit about the shoulder joint and why it is so complicated.

Dr. Benjamin Lindbloom (Guest): Absolutely Melanie. Well thank you very much for this opportunity. The shoulder, gives us the most motion of any other joint in the body, and as a result, it’s very prone to injuries that can be both traumatic in nature and also be related to just simply wear and tear or even overuse in normal patients. They can occur across the age range. I have some young patients, some old patients, and it occurs across patients of all activity levels. Oftentimes these injuries and pains can arise seemingly out of the blue and can be very complex and very debilitating to patients, and so it’s very important in seeing these patients that we really get a good history and really collect a lot of information about their specific symptoms and how they’re specifically impacting that patient’s life.

Host: So then what are some of the most common conditions you see that affect the shoulder. People hear about rotator cuff, sometimes they call it rotator cup. They don’t know really what that means, what that is, and how things like arthritis and bursitis and overuse injuries can affect the shoulder, what are you seeing every day Dr. Lindbloom?

Dr. Lindbloom: Absolutely, so soft tissue injuries around the shoulder tend to be more common than bony injuries. The rotator cuff is very prone to overuse because this is a very critical group of muscles; however, they’re a very small group of muscles, and so even though the shoulder is a ball and socket joint, the other ball and socket joint in your body is your hip. The hip has a big bony ball and a big bony socket. The shoulder has a big bony ball that’s sitting on a little bony golf tee of the shoulder blade called the glenoid. What actually acts as the socket then are these soft tissue structures such as the rotator cuff tendon, of which there are four, the joint capsule, and a soft tissue structure called the labrum. It’s very common to have injuries and inflammation related to use of the shoulder because these little soft tissue structures are doing a big job in holding and supporting your arm throughout the complex motion in ways that we use it in our everyday life. So probably the most common injuries that I do see as a shoulder and elbow specialist are related to the soft tissues about the shoulder.

Host: What a great anatomy lesson, Dr. Lindbloom. You’re such a good educator. So when we talk about chronic overuse and now there’s limits on baseball throwing, we try and work on our golfers not to hit the ground too often; what do you want listeners to know about those overuse injuries that take their toll on those soft tissues that help support the shoulder? What do you want us to know about training those and hopefully preventing some of these shoulder injuries?

Dr. Lindbloom: I think that that’s a great question. I think the first thing to understand is that the shoulder in and of itself plays a very critical role in an overall transmission of motion that starts at your neck and terminates at your hand. The thing that I like about being a specialist in the upper extremity is that the upper extremity has an ethos. That ethos is to position your hand in space. How you do that involves complex coordination between your shoulder blade moving on your chest, your shoulder moving at the ball and socket joint, your elbow moving and all of your wrist moving correctly. When you neglect or don’t pay attention to things like posture, or dedicated focused training on some of these specific stabilizing muscles, which are very small and very difficult and take a long time to train up in isolation, then you can see problems and breakdowns of that transmission of motion as a whole, and oftentimes patients will come in with a shoulder complaint and not understand why they’re having soreness in their neck or soreness in their shoulder blade, or soreness in their elbow and really miss that having one link in the chain off can actually ripple up and down the limb that contribute to further pain and further injury and further dysfunction in these patients.

Host: That’s a really good point, Dr. Lindbloom. So when people do come to you and they’ve got pain in their shoulder, their elbow, that general area, how do you diagnose what exactly the problem is? Is it mostly an MRI? Is that how you find them or are there other ways?

Dr. Lindbloom: So I think that having a dynamic, openminded approach to the patient is very important. So I begin with a very detailed history. My history is going to involve asking them questions about how their symptoms arose, what the nature of their symptoms are, what things seem to aggravate their symptoms and alleviate their symptoms, and kind of get an idea of how this patient is affected in their daily life by their complaints. I always start with plain film x-rays in my office because if we don’t understand the foundation upon which the soft tissue structures are attached with the bony osteology and anatomy, then we really can miss some more common diagnoses. It also allows me some good talking points with my patients to say hey this is your shoulder. Look, it’s not a bone problem. It’s going to focus more on the soft tissues. Clinical exam maneuvers about the shoulder are also very specialized and require a good level of understanding and detail of how these different small muscles contribute to a whole and also the ability to look at the posture of the whole limb, the motion of that patient’s shoulder blade on the thorax and other factors. How is their back posture? How is their neck posture? Is there any cervical spine or nerve root involvement where this pain is coming from the neck and being referred into the shoulder? There are a lot of things I need to keep a very keen diagnosed eye on and do workup in the clinical exam before I order further diagnostic testing such as an MRI to actually look at the soft tissues as well. I will not order a diagnostic test unless I have a specific question in mind that I’m seeking an answer to with that, and so in formulating those questions, I’m really focusing in on that history and physical examination.

Host: So now what? Once we have decided that, you know, they have pain in their shoulder, what is the first line of defense? And Dr. Lindbloom, what else do you want people to do at home? Are you an ice man or a heat guy? Can we brace our shoulder? Do you want us to reduce our activity, you know activity modification? Do you go right to a cortisone shot? I know this is a lot to throw at you, but tell us about the first line of defense for shoulder problems.

Dr. Lindbloom: Absolutely. I think that what I want to empower my patients to do is understand their specific pathology and understand what cornucopia of nonsurgical options are available to them. Oftentimes I use the analogy with my patients in the clinical setting that nonoperative treatment is like a buffet line and everyone’s plate at the end of that buffet line looks a little bit different. While there’s certainly a role for things like oral anti-inflammatories, ice and heat, which you mentioned, corticosteroid injection when done appropriately can also play a role; every patient kind of assembles that tray as they’re moving along that buffet line a little bit differently and that’s kind of the fun part of it. When I’m looking at treatment strategies they kind of fall into two modalities. One is addressing the inflammation that’s contributing to the pain initially. That can be done through medication such as the steroid injection and oral anti-inflammatory or a topical anti-inflammatory. I’m very big on topical anti-inflammatories actually in the shoulder because they have less of a capability to interact with other medications that my patient may be on and they also have less side effects. We also then need to look at some of the contributing factors and how we modify them so that we can prevent the inflammation from coming back. Oftentimes this is done through a home exercise program. I’m big on exercising and empowering my patients to have a good home exercise and range of motion program that they feel comfortable doing on their own. If needed, then we’ll involve our physical therapists or neuromuscular massage therapist to help as well because, especially in the shoulder, with such a dynamic motion, we need to address every contributing factor, whether that is a muscle balance problem, where maybe there are muscles that are tight that need to be loosened and muscles that are weak that need to be strengthened, whether that’s a postural problem. Now you did mention bracing. Shoulder bracing in and of itself is very difficult because of the motion in which it provides; however, I have used some attributes such as Kinesio tape or KT tape is the brand name of a product such as this to help with some shoulder stability in these patients.

Host: That’s good to know because you see the ads for KT tape and you wonder if it’s something that an orthopedic surgeon might use to help brace and support, so that’s really great to know. What about things like alternative, acupuncture, chondroitin, glucosamine, any of these kinds of things that are suppose to help lubricate a joint or make some of that pain go away, do you ever recommend some of those?

Dr. Lindbloom: I do. So I’m very big on making sure that my patient’s address underlying potentials to their inflammation. So if they do have any underlying autoimmune diseases, are those being medically managed? You know, addressing things like dietary concerns. Vitamin supplementation is very important. You know, I have the opportunity to practice in sunny Florida, but believe it or not, most of us in the United States are still vitamin D deficit, and so talking to my patients about vitamin D deficiency, talking to my patients about natural anti-inflammatory substances such as turmeric, talking to my patients about glucosamine/chondroitin and fish oil, which actually have grade A recommendations for pain relief and cartilage degeneration by the American Academy of Orthopedic Surgeons. I think that it’s important to find a resounding therapy that empowers that patient to manage their disease and really overcome it.

Host: Wow, great description, Dr. Lindbloom. So with hips and knees, you know the discussion can become surgical pretty quickly after you’ve tried all of those other modalities, but with the shoulder people really are like, oh I don’t want to discuss surgery. When does surgery become that discussion for the shoulder?

Dr. Lindbloom: I think that taking a conservative approach to surgery is always in the patient’s best attribute. I’ve never regretted not operating on someone, but all of us surgeons have regretted an operation on a patient when a complication arises. Surgery can be done in shoulder pathologies but it should always be performed to address a specific goal or a specific complaint that is not being managed appropriately with nonsurgical measures. In the shoulder, we have the privilege of being able to do both minimally invasive arthroscopic surgeries, which is operating with a camera through a very small portal incision and open surgical procedures, which involve larger incisions and larger undertaking such as a joint replacement. Joint replacements in the shoulder are actually becoming much more commonplace and have actually expanded tremendously in their indication and utilization among orthopedic surgeons. We’re now replacing shoulders for things like irreparable rotator cuff tears, end stage shoulder arthritis, shoulder fractures, both acute and non-united fractures, and that’s really what prompted me to even devote my career to shoulder/elbow surgery. One of my first patients that I encountered with debilitating shoulder arthritis was unable to even raise her arm up to the level of her shoulder. She couldn’t get into her cupboards. She couldn’t prepare her meals. She couldn’t prepare her hair, and that was very debilitating to this lady who lived by herself. We were able to perform what’s called a reverse shoulder replacement, and that patient at four weeks was able to get back to reach her hair, able to get back into her cupboard and it really changed her life and had a profound impact on her ability to care for herself, and so I think that when performed appropriately, the benefits can truly amaze the patients and outweigh some of those risks that we associate with surgery in the right patient population.

Host: That’s a great answer Dr. Lindbloom. As we wrap up, your best advice on preventing overuse or chronic injuries in the shoulder, what you would like us to know and take home from this segment about keeping that healthy, complicated shoulder joint.

Dr. Lindbloom: Absolutely, so we all have one body and it’s our job to see to it that we maintain our activity, that we keep it active and we use it to everything that it was designed to achieve. Maintaining an appropriate postural balance, maintaining a general overall noninflamed state in our body through our diet choices, maintaining motion is critically important for all of our joints. Your shoulder can literally open the world for you. If you will just take the time to devote and strengthen up that shoulder so that it can be as strong and as stable as it can be.

Host: Great advice. Thank you so much doctor for coming on and sharing your incredible expertise and telling us how we can keep healthy shoulders and some of the options and things we can try if we’re suffering from shoulder pain. You’re listening to Baycare Health Chat. For more information, please visit baycare.org. I’m Melanie Cole, thanks for tuning in.