Activities one takes for granted can be impacted by shoulder pain. Getting dressed, reaching cabinets, and lifting lightweight objects can be a challenge. Shoulder replacement surgery is an option for chronic issues.
Jaicharan Iyengar, MD, discusses shoulder pain and joint replacement.
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Shoulder Pain & Joint Replacement
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Jaicharan Iyengar, MD
Jaicharan Iyengar, MD is a nationally-recognized orthopaedic surgeon who specializes is surgical and non-surgical care of the shoulder, elbow and knee.Learn more about our physicians at www.dignityhealth.org/ourdoctors.
Transcription:
Shoulder Pain & Joint Replacement
Bill Klaproth (Host): Are you struggling with a painful shoulder? Then you know how tough it can be to get dressed, to reach up to get something out of the cabinet, and those sleepless nights laying in bed in pain. But you can find relief. Here to talk with us about shoulder pain and joint replacement is Dr. Jay Iyengar, a fellowship-trained shoulder surgeon at Dignity Health. Dr. Iyengar, thanks for your time. So what is the main cause of shoulder pain?
Dr. Jaicharan Iyengar, MD (Guest): Yeah, that's a complicated question, and oftentimes what we do as shoulder specialists is try to figure that out. And there's a variety of diagnoses that can contribute to shoulder pain. So I think it's important, first of all, to really understand the diagnosis. In some cases, it can be more of a soft tissue problem like the rotator cuff, or one of the tendons. In some cases, it's more of a bone problem, and that's when you're talking about things like arthritis. And so step one in any shoulder specialist's practice should be to try to diagnose the source of the pain more accurately.
Bill: So after the diagnosis, who is a good candidate for shoulder replacement surgery?
Dr. Iyengar: Yeah, that's a great question, and I get that all the time. If you're talking about a specific problem of shoulder arthritis, which is a wearing down of the cartilage in the shoulder joint, it leads to pain and stiffness, that's a diagnosis that goes along with the shoulder replacement surgery. And a good candidate in my practice is someone that has been diagnosed with severe arthritis, that has tried non-surgical treatments, and we can go into that in a little greater detail. If they've done that and they're not getting the relief and the function they want, that would be an ideal candidate for a shoulder replacement surgery.
Bill: So after diagnosis, you're looking for the severe arthritis, and then generally will you try physical therapy first before going to the shoulder replacement surgery?
Dr. Iyengar: Yeah, typically yes unless you're talking about a very advanced case where physical therapy is probably beyond improvement. In most cases, I'm going to try physical therapy and maybe even a cortisone injection as a first line measure to see if that creates improvement. And actually that can be quite effective in early stages of arthritis.
Bill: So when I think of shoulder replacement surgery, I instantly think to myself, "How do they do that? They're taking off my whole shoulder?" So I'm sure that's not the case. What is the procedure like, Dr. Iyengar?
Dr. Iyengar: Yeah, and that's why thank you for having me on the show. I love talking about it because a lot of people have heard of a knee replacement or a hip replacement, that they can't even conceptualize a similar procedure in the shoulder, so I'm happy to talk about it. In broad stroke, what you're talking about is using the natural intervals of muscles, meaning getting into the shoulders that the muscles can be separated apart, to access the joint, and then removing the arthritic surfaces of the shoulder joint that are worn out, and then replacing it with sort of a metallic ball and socket prosthesis. And so that's sort of what you're talking about conceptually, and it's done through an incision typically in the front of the shoulder, that's what I use, where there's a natural interval between the two muscles and the front of the shoulder, between the deltoid and the pectoralis, so you can get into the shoulder with very little trauma.
Bill: So as you're describing this, I'm thinking is this kind of like hip replacement? You're talking about a ball and a socket similar to hip replacement surgery but in the shoulder? Do I have that right?
Dr. Iyengar: Yeah, actually that's a very useful way to think about. There are some differences between the two. I think the concept is the same in that you're taking a worn out joint and you're replacing it with sort of a metallic ball and socket prosthesis. There are some differences in the shoulder in that the shoulder actually requires much more attention to the soft tissues in order to have a working joint. So you can't just rely on the prosthesis itself, the muscles have to be repaired as well. So there are some subtle differences, but I think the way you're thinking about it is correct.
Bill: So Dr. Iyengar, how long is the surgery? And what about the subsequent recovery after shoulder replacement surgery?
Dr. Iyengar: Yeah, so there's a little bit of variability because every situation is different, but generally speaking the procedure itself is about an hour and a half to two hours of surgical time, and most of my patients will either leave the hospital the same day or spend one night in the hospital and leave the next day after their surgery. So it's a little bit quicker than what you would come to expect from knee and hip replacements because you can actually walk pretty well because the legs aren't affected. And the recovery time, it also varies but the first six weeks are the critical time for recovery where the muscles are healing, the incision is healing, and you're starting physical therapy to improve your range of movement, so that first six to eight weeks is pretty critical.
Bill: And are you generally in a sling during that time except for physical therapy?
Dr. Iyengar: Yeah, I think for most of us in the shoulder community recommend wearing a sling for the first six weeks as a means of allowing it to heal. Now I've become a little more liberal about letting my patients take it off, even after two weeks, on their own to do exercises, and do basic hygiene activities. So I think we're getting to the point where our technology is better and we can allow earlier movement, but generally speaking, yeah the first six weeks a sling to support the arm is a good idea.
Bill: And people should expect normal range of movement after the surgery?
Dr. Iyengar: That's a good question. So not quite normal but very close to it. Keep in mind that by the time someone gets to my office, they're usually in pretty bad shape. They're usually on more the severe stage of arthritis, they've lost a lot of their range of movement, and they can't even do simple functional activities. Most of those patients are going to recover about 90% of normal function with the shoulder replacement and the appropriate rehab. Now do they ever get to 100%? I'm not sure that's the case, but from where you started, typically you're going to see such an improvement that you won't notice that last 10%.
Bill: So with knees and hips, I know generally there is a replacement time of years where, "Okay it's going to last ten to fifteen years or so." How does that work with shoulder replacement?
Dr. Iyengar: Yeah, that's an excellent question. So similar to hip and knee replacement, these are mechanical prostheses and they can wear down over time. Now the one advantage in the shoulder is that you don't walk on your arms so you don't put the same kind of weight bearing stresses on a shoulder replacement, so we think that helps preserve the joint for a longer period of time. And there are case reports and literature of the original shoulder replacements that were done in the seventies still functioning well in 2018. That's actually still out there, so they can last a very long time. I tell my patients expect about fifteen to twenty years out of your first shoulder replacement, and anything beyond that, I consider it gravy.
Bill: Absolutely. So is shoulder replacement surgery becoming more and more common?
Dr. Iyengar: Yeah, it really is. This past year I think it was the third most replaced joint behind the hip and the knee. So the word is getting out there that this can be done, and previously I think a lot of patients and even doctors thought that if you had a bum shoulder, that was sort of it. But we're trying to get the word out there through things like podcasts and various sources that kind of spread the word, that there are other options.
Bill: So let me ask you this as far as prevention goes. Are there things we can be doing? Things we should be doing to protect our shoulders throughout our daily routines?
Dr. Iyengar: Yeah, that's a controversial issue because we can't say for sure that we can prevent arthritis. Sometimes it happens just in the natural course of life, but there are some things we do know. We do know that keeping your shoulder mobile tends to help protect and nourish the cartilage. So range of movement or range of mobility is an important way to keep your cartilage healthy. We also know that keeping the muscles strong can protect you against some of the downsides of arthritis. So someone with good muscular cartilage will tend to have a more resistant joint to deterioration. Beyond that, there's a lot of interest out there in kind of natural or holistic ways to prevent arthritis. I can't say that we've found a solution yet, but there are certain things that I talk to my patients about like getting a balanced diet with a lot of leafy greens, anti-oxidants like you find in berries seem to be very helpful in warding off arthritis. There's some evidence of things like turmeric actually have anti-inflammatory properties. So there are things that you can do, even if they aren't medication treatments, I think there are lifestyle choices you can make that can help you preserve your shoulders.
Bill: Well that's really good to know, and I'm thinking for someone experiencing shoulder pain, human nature we may put it off. "I'm just going to live with this pain. I'm going to tough it out." Sounds like it's better to go in sooner, you have a better efficacy rate if you get to that shoulder sooner than somebody that just lets it go for years and years. Is that right?
Dr. Iyengar: Yeah, I think that's absolutely correct, and that's some of the gospel that we preach. You don't have to live with shoulder pain. In a lot of cases they can be treated and the earlier you get to it, oftentimes the more options you have. What I like to see is if I get a patient in with very early stage arthritis in their shoulder, oftentimes whether it's physical therapy, injections, or even like an orthoscopic treatment, which is a minimally invasive treatment, they can show a lot of improvement. If I get to a patient in the later more severe stages, oftentimes we're talking about some more invasive replacement options. So I agree with what you said, if you get to it earlier you just have a lot more things available to your options.
Bill: Well Dr. Iyengar, thank you so much for the great discussion today. We really appreciate it. And for more information, please visit www.DignityHealth.org. That's www.DignityHealth.org. This is Hello Healthy, a Dignity Health podcast. I'm Bill Klaproth, thanks for listening.
Shoulder Pain & Joint Replacement
Bill Klaproth (Host): Are you struggling with a painful shoulder? Then you know how tough it can be to get dressed, to reach up to get something out of the cabinet, and those sleepless nights laying in bed in pain. But you can find relief. Here to talk with us about shoulder pain and joint replacement is Dr. Jay Iyengar, a fellowship-trained shoulder surgeon at Dignity Health. Dr. Iyengar, thanks for your time. So what is the main cause of shoulder pain?
Dr. Jaicharan Iyengar, MD (Guest): Yeah, that's a complicated question, and oftentimes what we do as shoulder specialists is try to figure that out. And there's a variety of diagnoses that can contribute to shoulder pain. So I think it's important, first of all, to really understand the diagnosis. In some cases, it can be more of a soft tissue problem like the rotator cuff, or one of the tendons. In some cases, it's more of a bone problem, and that's when you're talking about things like arthritis. And so step one in any shoulder specialist's practice should be to try to diagnose the source of the pain more accurately.
Bill: So after the diagnosis, who is a good candidate for shoulder replacement surgery?
Dr. Iyengar: Yeah, that's a great question, and I get that all the time. If you're talking about a specific problem of shoulder arthritis, which is a wearing down of the cartilage in the shoulder joint, it leads to pain and stiffness, that's a diagnosis that goes along with the shoulder replacement surgery. And a good candidate in my practice is someone that has been diagnosed with severe arthritis, that has tried non-surgical treatments, and we can go into that in a little greater detail. If they've done that and they're not getting the relief and the function they want, that would be an ideal candidate for a shoulder replacement surgery.
Bill: So after diagnosis, you're looking for the severe arthritis, and then generally will you try physical therapy first before going to the shoulder replacement surgery?
Dr. Iyengar: Yeah, typically yes unless you're talking about a very advanced case where physical therapy is probably beyond improvement. In most cases, I'm going to try physical therapy and maybe even a cortisone injection as a first line measure to see if that creates improvement. And actually that can be quite effective in early stages of arthritis.
Bill: So when I think of shoulder replacement surgery, I instantly think to myself, "How do they do that? They're taking off my whole shoulder?" So I'm sure that's not the case. What is the procedure like, Dr. Iyengar?
Dr. Iyengar: Yeah, and that's why thank you for having me on the show. I love talking about it because a lot of people have heard of a knee replacement or a hip replacement, that they can't even conceptualize a similar procedure in the shoulder, so I'm happy to talk about it. In broad stroke, what you're talking about is using the natural intervals of muscles, meaning getting into the shoulders that the muscles can be separated apart, to access the joint, and then removing the arthritic surfaces of the shoulder joint that are worn out, and then replacing it with sort of a metallic ball and socket prosthesis. And so that's sort of what you're talking about conceptually, and it's done through an incision typically in the front of the shoulder, that's what I use, where there's a natural interval between the two muscles and the front of the shoulder, between the deltoid and the pectoralis, so you can get into the shoulder with very little trauma.
Bill: So as you're describing this, I'm thinking is this kind of like hip replacement? You're talking about a ball and a socket similar to hip replacement surgery but in the shoulder? Do I have that right?
Dr. Iyengar: Yeah, actually that's a very useful way to think about. There are some differences between the two. I think the concept is the same in that you're taking a worn out joint and you're replacing it with sort of a metallic ball and socket prosthesis. There are some differences in the shoulder in that the shoulder actually requires much more attention to the soft tissues in order to have a working joint. So you can't just rely on the prosthesis itself, the muscles have to be repaired as well. So there are some subtle differences, but I think the way you're thinking about it is correct.
Bill: So Dr. Iyengar, how long is the surgery? And what about the subsequent recovery after shoulder replacement surgery?
Dr. Iyengar: Yeah, so there's a little bit of variability because every situation is different, but generally speaking the procedure itself is about an hour and a half to two hours of surgical time, and most of my patients will either leave the hospital the same day or spend one night in the hospital and leave the next day after their surgery. So it's a little bit quicker than what you would come to expect from knee and hip replacements because you can actually walk pretty well because the legs aren't affected. And the recovery time, it also varies but the first six weeks are the critical time for recovery where the muscles are healing, the incision is healing, and you're starting physical therapy to improve your range of movement, so that first six to eight weeks is pretty critical.
Bill: And are you generally in a sling during that time except for physical therapy?
Dr. Iyengar: Yeah, I think for most of us in the shoulder community recommend wearing a sling for the first six weeks as a means of allowing it to heal. Now I've become a little more liberal about letting my patients take it off, even after two weeks, on their own to do exercises, and do basic hygiene activities. So I think we're getting to the point where our technology is better and we can allow earlier movement, but generally speaking, yeah the first six weeks a sling to support the arm is a good idea.
Bill: And people should expect normal range of movement after the surgery?
Dr. Iyengar: That's a good question. So not quite normal but very close to it. Keep in mind that by the time someone gets to my office, they're usually in pretty bad shape. They're usually on more the severe stage of arthritis, they've lost a lot of their range of movement, and they can't even do simple functional activities. Most of those patients are going to recover about 90% of normal function with the shoulder replacement and the appropriate rehab. Now do they ever get to 100%? I'm not sure that's the case, but from where you started, typically you're going to see such an improvement that you won't notice that last 10%.
Bill: So with knees and hips, I know generally there is a replacement time of years where, "Okay it's going to last ten to fifteen years or so." How does that work with shoulder replacement?
Dr. Iyengar: Yeah, that's an excellent question. So similar to hip and knee replacement, these are mechanical prostheses and they can wear down over time. Now the one advantage in the shoulder is that you don't walk on your arms so you don't put the same kind of weight bearing stresses on a shoulder replacement, so we think that helps preserve the joint for a longer period of time. And there are case reports and literature of the original shoulder replacements that were done in the seventies still functioning well in 2018. That's actually still out there, so they can last a very long time. I tell my patients expect about fifteen to twenty years out of your first shoulder replacement, and anything beyond that, I consider it gravy.
Bill: Absolutely. So is shoulder replacement surgery becoming more and more common?
Dr. Iyengar: Yeah, it really is. This past year I think it was the third most replaced joint behind the hip and the knee. So the word is getting out there that this can be done, and previously I think a lot of patients and even doctors thought that if you had a bum shoulder, that was sort of it. But we're trying to get the word out there through things like podcasts and various sources that kind of spread the word, that there are other options.
Bill: So let me ask you this as far as prevention goes. Are there things we can be doing? Things we should be doing to protect our shoulders throughout our daily routines?
Dr. Iyengar: Yeah, that's a controversial issue because we can't say for sure that we can prevent arthritis. Sometimes it happens just in the natural course of life, but there are some things we do know. We do know that keeping your shoulder mobile tends to help protect and nourish the cartilage. So range of movement or range of mobility is an important way to keep your cartilage healthy. We also know that keeping the muscles strong can protect you against some of the downsides of arthritis. So someone with good muscular cartilage will tend to have a more resistant joint to deterioration. Beyond that, there's a lot of interest out there in kind of natural or holistic ways to prevent arthritis. I can't say that we've found a solution yet, but there are certain things that I talk to my patients about like getting a balanced diet with a lot of leafy greens, anti-oxidants like you find in berries seem to be very helpful in warding off arthritis. There's some evidence of things like turmeric actually have anti-inflammatory properties. So there are things that you can do, even if they aren't medication treatments, I think there are lifestyle choices you can make that can help you preserve your shoulders.
Bill: Well that's really good to know, and I'm thinking for someone experiencing shoulder pain, human nature we may put it off. "I'm just going to live with this pain. I'm going to tough it out." Sounds like it's better to go in sooner, you have a better efficacy rate if you get to that shoulder sooner than somebody that just lets it go for years and years. Is that right?
Dr. Iyengar: Yeah, I think that's absolutely correct, and that's some of the gospel that we preach. You don't have to live with shoulder pain. In a lot of cases they can be treated and the earlier you get to it, oftentimes the more options you have. What I like to see is if I get a patient in with very early stage arthritis in their shoulder, oftentimes whether it's physical therapy, injections, or even like an orthoscopic treatment, which is a minimally invasive treatment, they can show a lot of improvement. If I get to a patient in the later more severe stages, oftentimes we're talking about some more invasive replacement options. So I agree with what you said, if you get to it earlier you just have a lot more things available to your options.
Bill: Well Dr. Iyengar, thank you so much for the great discussion today. We really appreciate it. And for more information, please visit www.DignityHealth.org. That's www.DignityHealth.org. This is Hello Healthy, a Dignity Health podcast. I'm Bill Klaproth, thanks for listening.