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Melanie Cole (Host):  If shoulder pain is limiting your daily activity, at ChristianaCare, we’re able to provide a variety of interventions, surgical and nonsurgical based on what’s best for you. This is ChristianaCare’s Moving Freely podcast series. I’m Melanie Cole and joining me today, is Dr. Bradley Sandella. He’s a Sports Medicine Physician and the Program Director of Sports Medicine at ChristianaCare. Dr. Sandella thank you so much for joining us today. Tell us a little bit about the shoulder joint. It’s really a complicated joint and motion and mobility has it’s price. Tell us a little bit about some of the most common conditions you see affecting the shoulder joint.

Bradley Sandella, DO, ATC (Guest):  Hello Melanie. Thank you. The shoulder is quite a complex joint. It actually comprises four joints all together. We typically think about the most important joint the ball and the socket which we talk about primarily whenever we talk about the shoulder. And several conditions affect individuals on a frequent basis. We have conditions like impingement syndrome where your ability to lift your arm either in front of you or to the side is limited or reduced or contributed to the pain. The are some issues where you have instability, where your shoulder doesn’t feel stable in the joint and it feels like it may either slip out or pop out and it’s not seated correctly.

And then there’s also conditions that maybe are related to more just muscle injury where you get a strain or a sprain. But those are primarily the large groups that constitute the injuries that we see with the shoulder.

Host:  Tell us about some of the shoulder symptoms. I mean people get rotator cuff pain, even though they call it the rotator cup, they don’t even know what that is. Maybe they are a golfer or a tennis player or they play baseball, or they are a weekend warrior. Tell us about some of the reasons that we are feeling that shoulder pain and when you feel it’s time to go see someone for treatment.

Dr. Sandella:  The classic symptom that I hear most people describe when they are talking about shoulder problems is pain. And specifically night pain. Pain that you might experience that wakes you up from sleep is a classic hallmark for a lot of shoulder problems that are related to the rotator cuff or the group of muscles that help move your shoulder around the joint. Secondary to pain, the other symptom that most people will feel will be either tightness where if they try to elevate their shoulder, they feel like they are restricted, or they might even have a little bit of a sense of spasm or muscle spasm where they feel a catching or a locking. And then finally, they might have a sense of instability where the shoulder just feels like it’s clicking or popping.

Host:  So, how do you diagnose it, because there are as you said, so many things that could go wrong with the shoulder. Do you use diagnostic ultrasound? Is that something that you can use as an alternative to MRI for evaluation? How do you diagnose it?

Dr. Sandella:  that’s becoming one of our mainstays in treatment is the use of diagnostic ultrasound. After we perform a sound physical exam, a diagnostic ultrasound that we perform in the office can give us a lot of information about what’s going on with the shoulder. The other thing is A: it’s done in the office, B:  it’s cost effective where it’s actually a relatively inexpensive thing to perform and C:  we can actually do it while the person is either moving their shoulder or while they are at rest. So, it gives us a look at the shoulder statically and dynamically. Or at stable or while moving.

Host:  So, then how do you decide what kinds of treatments? What’s the first line of defense? Is physical therapy and home exercise, is activity modification? Kind of give us a little summary of some of the things you might try first and include for me if you would, because it’s a question I get all the time, ice, heat, bracing. Tell us about some of these modalities that you might try before we get into some other types of modalities.

Dr. Sandella:  Treatment options are often are tailored to exactly what the patient is experiencing along with how willing they are as far as to pursue how aggressive they want to be. And I usually make it a joint decision. But when it comes time to start initiating treatment, I think about the modalities and I personally like to use ice initially. I think it helps kind of cool off inflammation and calm down and angry joint. If a problem is more chronic in nature, I’ll consider using heat, but ice is a preferred method at least to start treatment.

After we look at the ice and heat treatment options, we start thinking about medications and those are an option but before I get to there; I like to pursue something that’s a little bit safer which is either therapy, either home exercises through a home exercise program or a physical therapy driven exercise program which is a little bit more formalized. That way we can get the patient to actively start using their shoulder without necessarily introducing something foreign to the body.

Host:  Well certainly it’s great for patients to be able to do some of these things and try some of these modalities before they even think about any kinds of surgical procedures. What about things like biologics and medicational interventions? NSAIDs, all of these. Where do they fit into the shoulder picture?

Dr. Sandella:  Great question. Once we start to consider advancing treatment options and we start to think about using some type of medication or therapeutic; it becomes kind of the choice to see which is effective and which is a cost versus risk benefit. Anti-inflammatories are often a mainstay we reach for. But I don’t like to use them for an extended period of time even beyond two weeks. If we are starting to use a medication like a nonsteroidal anti-inflammatory for greater than two weeks; there’s some potential side effects that you need to consider like injury to the kidneys or have a bleeding condition that’s present. So, I like to use them very sparingly.

When we start to advance to the next line, maybe an injection technique for treatment; the one thing that we think about is corticosteroid or the proverbial steroid injection. That seems to provide a lot of benefit especially if there’s an inflammatory condition. It helps cool off the irritation and allow the shoulder to settle down so it can heal maybe with a formalized exercise program.

Unfortunately, when you are using a steroid injection, it’s not as therapeutic as more of a helpful agent to calm inflammation. When we start to talk about advanced treatment options like biologics, you’re starting to move into a territory where the evidence is a little bit limited right now. But we’re starting to see that there could be benefit from using either platelet rich plasma injections or even STEM cell injections for treating more chronic conditions where we can attempt to have the muscles regenerate into a more healthy condition.

Host:  I would imagine Dr. Sandella, that you get this question a lot, but how often? How often can you get injection procedures? Some people want them more often than some doctors are willing to give. How often is really the best practice?

Dr. Sandella:  We try to use injections as limited as needed but once we initiate a treatment, I like to space out my corticosteroid injections with at least a three to four month window in between injections. This way we can decrease the chances of hurting either the soft tissue structures like muscle or tendon as well as the joint. There’s no real evidence to say how many is too many but, no more than three a year is a safe way to go.

Host:  Do these issues tend to resolve themselves? Do rotator cuff tears even small ones tend to heal themselves? How does that work with the shoulder joint and various injuries?

Dr. Sandella:  The shoulder joint and the conditions that afflict it, they will tend to heal but often not on their own. What we tend to see is people might develop some partial tearing into a tendon or a muscle tissue that usually needs some type of treatment to assist in it’s recovery. And like we spoke of earlier, often it’s physical therapy or some type of dedicated exercise program. One of the concerns I see with a lot of people is they are very smart and what they do is they tend to rest their shoulder but unfortunately they tend to rest it too long and they really limit their motion and then what tends to happen is it tends to start getting very kind of limited motion sets in where you can’t move it as freely and that becomes even more uncomfortable.

So, even though a person might be trying to do the right thing by resting their shoulder; prolonged rest and not moving it can actually lead to further and different types of problems.

Host:  Well it certainly can and as we get ready to conclude here; prevention of should injuries, whether you are a golfer and you are hitting the ground or a baseball player, you’re in sports medicine; what do you want listeners to know about prevention, taking good care, making sure they have good strong shoulders so that they can keep up with those activities. I mean there’s even limits and pitching for throwing arms even in the littlest guys. So, what do you want people to know about protecting those shoulder joints?

Dr. Sandella:  Yeah, protecting your shoulder is critical. And as we talked about, there is so much motion and so much activity that happens there that we need to be pretty cognitive about staying on top of and preventing injuries. A couple easy ways to do this is making sure you are doing some stretching, overhead stretching and to the side to really maintain your internal, external rotation as well as full flexion and abduction, moving your arm to either in front of you or to the side is key. Doing some basic strengthening exercises with either stretchy bands or even a light dumb bell can be very effective in preventing injuries.

And just being careful when you are lifting objects up and trying to pick things up that you are using proper technique as to not put yourself in a compromised position leading to a shoulder injury or possibly something even more extreme.

Host:  Well great advice Dr. Sandella. Thank you so much for joining us today. And that concludes this episode of ChristianaCare’s Moving Freely Podcast Series. To learn more about programs and services please visit www.christianacare.org/sportsmedicine for more information and to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other ChristianaCare podcasts. I’m Melanie Cole.