Maggie McKay (Host): We usually don't appreciate our shoulders until there's a problem and we're in pain or they don't work. But how do you know when it's time to seek help for shoulder pain? Joining me today is Dr. Bo Naysmith Loy, orthopedist at Northern Inyo Healthcare District to talk about arthroscopy, shoulder pain and more. I'm Maggie McKay. Welcome to Mountain Medicine, the official podcast of Northern Inyo Healthcare District. Thank you for being here today, Dr. Loy. It's a pleasure to have you.

Dr Bo Nasmyth Loy: Yeah. Maggie, thanks for having me. I appreciate it.

Maggie McKay (Host): Absolutely. When it comes to shoulder pain, what are some of the symptoms that make it enough to go to the doctor or the ER?

Dr Bo Nasmyth Loy: So my specialty is sports medicine and arthroscopy. And so if you're out there skiing, hiking, backpacking, rock climbing, and you fall and your shoulder hurts sometimes, you know, myself included, I would try to ignore it for a few days, but certain injuries need to be seen sooner than others. And it's one of those. If your shoulder's not getting better the way you expect, or you still have lagging pain, particularly if you have loss of function, that's time to get checked out and that's time to make sure that you get seen. You don't have an injury that needs to get treated.

Maggie McKay (Host): And what's the main cause of shoulder pain?

Dr Bo Nasmyth Loy: Well, it depends on the age group. So if we break it down into the older age group, just the main cause for a lot of things is arthritis and that's kind of his own different beast. And arthritis pathway would go down towards possible injections and maybe replacement type of surgery. Total shoulder or a reverse total shoulder. more up my alley and I do those surgeries, but more up my alley. And about this talk is sports medicine and one of the more common ones is rotator cuff injury or labral injuries.

Maggie McKay (Host): And what are the risks? I mean like lifestyle, like sports that you do?

Dr Bo Nasmyth Loy: I mean, if you're not using your shoulder and you're not out there being active, you're probably not gonna tear your rotator cuff at a young age. Now it's, it's common in older age to do it with lifting things overhead, and that's not uncommon. But my philosophy is, you know, go out there, live a good life, be active. You injure yourself. Come on in, we'll get you fixed up.

Maggie McKay (Host): So let's say you injure yourself. You need to go to the doctor, but not the er, but you gotta wait for an appointment. So what do you do to relieve the pain in between heat or ice? Ice or heat? Which kind of pain reliever?

Dr Bo Nasmyth Loy: Yeah, that's like still the great myth. No one really has a direct answer, but I, just believe in if it's worked for you for 10 years, don't let some doctor tell you otherwise. If ice seems to work for you at night to cool things down, but you need to warm yourself up with a heating pad in the morning, then go for it. In the acute phase and we've all probably rolled our ankles and they get swollen. Ice can help with swelling, ice, and elevation. If it's your shoulder, you can't really elevate it, but ice compression, elevation and then, pick your poison for home, medications that you can get, like Tylenol and Ibuprofen, which I still use frequently. And I find them the best first line is to start there.

Maggie McKay (Host): And can shoulder pain be a warning of a heart attach?

Dr Bo Nasmyth Loy: So definitely not up my alley, but Absolutely. So radiating shoulder pain with. trauma and you just wake up and you have that jaw upper shoulder pain rating to your left side. That can be very concerning. So if you have cardiac risk, that's absolutely something to take seriously.

Maggie McKay (Host): So if you're right-handed or left-handed, do you have more chance of injuring the main arm that you use?

Dr Bo Nasmyth Loy: The short answer is they're about the same, but from just, anecdotally, people tend to injure their dominant side because they tend to be doing things more. So a lot of this is lifting things overhead and people tend to favor their dominant arms. So it's a little bit more likely on the dominant side.

Maggie McKay (Host): What does it mean if you are moderately active and you say lift weights three times a week and your shoulder is constantly clicking, like when you just move it around toward the back, is that a bad thing?

Dr Bo Nasmyth Loy: So not all pops and clicks are bad, but a mechanical symptom, like a blocked range of motion is bad and that's often the soft tissue injury kind of flapping in the joint. But I tell my patients this all the time, I've personally had surgery on one extremity. And I say, oh look, I had surgery on this one extremity, and I can bend my knee and pop it, and that's my non-operative knee. And things just pop sometimes, and that's okay. But popping with pain or not being able to perform the way you want to is concerning. And that's something to be checked out. In particular, if there's a specific motion you can do with your arm, that could be indicative of a labral injury, the soft tissue around the shoulder, and that could be kind of flapping into the joint. So that's something to consider.

Maggie McKay (Host): All right. Crazy question, but is it possible for the position you sleep in to cause over time, shoulder damage?

Dr Bo Nasmyth Loy: Pretty unlikely to cause shoulder damage for sleeping. Funny generally speaking, if you're going to injure your shoulder, it needs to be bad enough that you wouldn't sleep through it. However, after surgery, yes. So If you have surgery and you get your shoulder fixed, then we often use slings and immobilizes to keep the shoulder in a safe position to prevent these abnormal positions. But no, it's not common to have slept for 10 years in a certain way and be like, oh, now you need surgery.

Maggie McKay (Host): You know, when we age sometimes people have to get hip replacements. what about Shoulder? Do they wear out?

Dr Bo Nasmyth Loy: So the beauty of it is, your hip, your knee, they're weightbearing joints and the shoulder's not weightbearing technically. So they don't wear out the same kind of way. And that's actually one of the things that I did an extra year of training to go make sure I could do shoulders and total shoulders and reverse total shoulders with an expert. It doesn't wear out, they are fantastic surgeries. And if a hip fails, there's all sorts of revisions you'd have to do. And if a shoulder fails with the implants that I use, you can go from an anatomic total shoulder in a relatively easy process, flip it to a reverse.

And the indications for that are oftentimes if the soft tissue and the muscles about the shoulder are failing, you can then, go to a reverse sometime down the road. So shoulders are a great kind of Replacement surgery. Hips are more common, knees are more common, but shoulders are fantastic.

Maggie McKay (Host): Tell us about the treatment. you mentioned what you use. how involved is it and what's the recovery like, and what do you do?

Dr Bo Nasmyth Loy: Let's pick one diagnosis and go down that path and then we can kind of, talk a bit more about it. So if you injure your shoulder, you now have weakness lifting your shoulder in front of you, or to the side of you, and you've torn your rotator cuff, and your MRI shows a rotator cuff tear. Then the philosophy is you need to get that tendon and reattach it back to the bone. So my preferred method is arthroscopic rotator cuff repair, and that means using poke holes. So you can fit in instruments about the size of a BIC pen, so pretty small. And then you can inflate the joint with water so you can see everything.

And you see this torn rotator cuff off the bone and you debride the diseased tissue and then you. Scrape the bone to create this healthy bleeding bed of bone. And then you take this tendon and you reattach it to this bleeding bed of bone so that this bone wants to heal back to this tendon. And I use, what is called a double row technique, and that is using sutures and anchors on one side to pass it up and through the rotator cuff, bring it back and over, and compress it down to that bleeding bone with a second lateral row of anchors and sutures. And they perform quite well and it's one of my favorite surgeries.

Maggie McKay (Host): And what's recovery like?

Dr Bo Nasmyth Loy: So we mentioned that earlier. The shoulder, I mobilizer and the sling. So I kind of tell people, everyone's a little different, but I tell people it's three sets of six weeks. So six weeks of healing, and in that phase, it's real gentle range of motion exercises. You work with your physical therapist, but you are wearing a sling and an immobilizer for six weeks, and then six weeks of working on range of motion exercises, and then followed by six weeks of working on strengthening exercises.

And then, a lot of people feel better quickly, but the process, and I think ticket is a good sign. Sometimes people even up to a year later are saying that their shoulder feels stronger and stronger. So once you've torn that tendon and it's nonfunctional, you gotta let that thing heal down before you move it. But once it does, people tend to feel much, much better and much stronger.

Maggie McKay (Host): Dr. Loy, what about arthroplasty?

Dr Bo Nasmyth Loy: Yeah, so shoulder replacement surgeries, it's a different beast. So that's more the arthritic shoulder, that's the shoulder that isn't a torn rotator cuff. And to go forward with a anatomic shoulder replacement versus a reverse total shoulder replacement, that would indicate that you have to have your rotator cuff. And that's a little different. So that's using an open incision, kind of what you'd think surgery would be. Cutting down, dissecting down, finding the joint. And then you debride the disease in arthritic joint and you replace both sides of the joint. So some surgeries are what's called hemi arthroplasty, just half of it. You replace just the ball side.

But usually speaking and more common is a total. And that's replacing both the ball and the socket. And you cut out the diseased portion and you implant metal implants with a high molecular weight polyethylene liner, which a fancy way of saying plastic between the two. And the recovery's quite nice. So you have to wait for a few of the tendons to heal. But, people can oftentimes wake up immediately and start moving their shoulder and they know, oh, it's not arthritic. It doesn't pop and click and bounce around anymore. This seals better. It's arthroplasty is, it's a wonder that when people walk in with really bad joints, how quickly they feel better.

Maggie McKay (Host): How did you choose sports medicine?

Dr Bo Nasmyth Loy: Yeah, so I guess I chose surgery first. I was always very hands on. I knew I wanted to work with my hands and physically kind of build something. And then within that, because of the building, and I like the aesthetics of, orthopedic surgery. It's just you're actually building something, you're using your hands. You can see it on x-ray. It's very mechanical. And then within it, sports medicine. young sports injuries, I take people who were once very healthy, very active, and they can't do it. And then with surgery, with help with, hopefully guidance and education, they get back to it.

So to me it's taking someone in the prime of their life and getting 'em back to it as quickly as possible. I really enjoy that and it's a really broad field. Sports is quite broad and some other fields may be considered more narrow, but I just, I like it.

Maggie McKay (Host): Were you an athlete in grade school? High school?

Dr Bo Nasmyth Loy: Yeah, I was a fantastic athlete in grade school. In the class of four of us at my really small elementary school, I was in the top five. And then I played sports in high school. I played intermurals in college and I played all that kind of stuff. And I still, you know, ski and ride dirt bikes and surf when I can. And you don't live out in the Sierras and surf. but no, I wasn't like a D1 college athlete or anything.

Maggie McKay (Host): Okay. Because sometimes, football players have an injury and they get healed and they're like, I'm gonna do that. I'm gonna do it for other people. So earlier we mentioned about you hurt yourself, you have to go get it treated, but maybe you can't get into an appointment fast enough. How crucial is it in some cases, to get to see someone right away, if you can't get into the doctor, just go to the ER or?

Dr Bo Nasmyth Loy: Well, yeah. So if you've dislocated your shoulder and people generally have a good sense of it. If you dislocate your shoulder, if you can't control bleeding, if you're feeling so sick or your chest hurts, or you thought you maybe just hurt your shoulder and it's radiating to your neck and you're worried about a heart attack, go to the ER. But if you twist your knee and it's popping and clicking and it's two o'clock in the morning when you get back from the mountain because you went out to dinner or whatever, it's just late. Do you need to go to the ER because your knee's hurting and it doesn't feel right after you twisted it? No.

You can wait till the next day to go and you can see your primary care doctor or you can see us. And people generally know if you are concerned and you're scared and you can't sleep because of it, get checked. if you have a good sense of it and it feels like that time you heard it a few years ago, that's okay to wait and like we said, ice elevate, ibuprofen, Tylenol, that should be enough.

Maggie McKay (Host): Good to know. Dr. Loy, this information is so useful. Thank you so much for sharing your knowledge and your expertise and all those years of med school.

Dr Bo Nasmyth Loy: Thanks Maggie. I appreciate it. In all those years of, competitive elementary athletics, right.

Maggie McKay (Host): That's Dr. Bo Naysmith Loy orthopedist at Northern Inyo Healthcare District. For a consultation with Dr. Loy, please call Northern Inyo Associates Orthopedic Clinic at 760-873-2605. And if you found this podcast helpful, please share it. Social channels and check out our entire podcast library for topics of interest to you. Thank you for listening to Mountain Medicine, the official podcast of Northern Inyo Healthcare District. I'm Maggie McKay. Be well.