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Introduction: Compassion trust courage, innovation, the values of Temecula Valley Hospital. We proudly present TVH Health Chat. Here's Melanie Cole.

Melanie Cole: Welcome to TVH Health Chat with Temecula Valley Hospital. I'm Melanie Cole, and today we're discussing where we've gone in the world of shoulder surgery. Joining me is Dr. Andrew Erwetman, he's Board Certified Orthopedic Surgeon and a member of the medical staff at Temecula Valley Hospital. Dr. Erwetman, it's a pleasure to have you join us today. I'd like you to start with a little physiology lesson for the listeners. Tell us a little bit about the shoulder joint and how complicated it is.

Dr. Erwteman.: Hi, thanks for having me. So the shoulder that's one of the most mobile joints in the entire body. It has a lot of degrees of freedom and therefore it's a little bit more likely to become unstable or have issues.

Host: So, what are some of the most common conditions that you see that affect the shoulder? What types of conditions cause the shoulder joint to have pain or to break down?

Dr. Erwetman: So, when you think about that, you tend to break it down into age groups. So, you've got your younger age groups that are playing sports and are at risk of, you know, sprains and strains and things like dislocations, where you might have some tearing inside the shoulder of the structure called the labrum and the capsule. And then you have middle age groups, sometimes doing repetitive work or heavy physical labor, and you can start to get some rotator cuff disease. And then as you move into your 50s, 60s, and beyond you start seeing the higher incidents of tearing of the rotator cuff, which is a group of muscles and tendons in the shoulder, and at the most extreme end of that, you can have a very large tear that can end up deteriorating the joint. And it's something called rotator cuff tear arthroplasty. It becomes like a severe arthritis of the joint from that rotator cuff problem that you've had. You can also have arthritis of the shoulder, which is not related to the rotator cuff, and that can eventually get to the point just like any other joint, hip, or knee where it's bone on bone and causing a lot of pain and grinding sensation in there.

Host: Doctor, thank you for that. And since the shoulder joint is so complicated and motion and mobility, have their price. Tell us a little bit about how you even diagnose the cause of the shoulder pain. If someone is a golfer or there, you know, they've torn their rotator cuff, how do you know, how do you diagnose this?

Dr. Erwetman: So, you start in the back of your mind with probabilities based on age. And then with that, you listen to the patient carefully, you take a good history. That's always the number one thing to do because sometimes you get your answer right there. Sometimes it's related to a specific injury and now you have your answer and your diagnosis, but you put that together with a very thorough physical exam. And in some cases we get imaging studies, whether they're x-rays or advanced imaging studies like a CAT scan or an MRI, and you put it all together. Other times you might use some numbing injections called diagnostic injections to try to find the pain generator in the shoulder by numbing certain areas. And if it helps the person, then you can isolate it a little better, but that's basically how you start.

Host: Well, then talk about first line treatments because you know, we hear with hips and knees about replacements, but shoulders it's a little bit more of a bigger deal. And it's a discussion that happens a little further on down the line. So start with your first line of defense for joint pain. Tell us about medicational interventions. And then I'd like you to tell us about injection procedures and when and why you would use those.

Dr. Erwetman: Sure. So, you know, you have to first talk about them as different problems because when you talk about rotator cuff disease in a shoulder that is not arthritic, the first line of treatment is generally physical therapy to work on strengthening the muscles around the shoulder, fixing the posture, which authors the biomechanics of the shoulder and can lead to what we call impingement and inflammation in the rotator cuff and the bursa in that area, which can be very painful. So physical therapy is oftentimes the first line of treatment. In some cases you may add an anti inflammatory medication such as ibuprofen or Aleve, or, you know, a number of others that can be prescription based. Personally, I try to be very careful about that, especially in the older population, due to the negative effects that we know anti-inflammatories have, whether it's contributing to stomach ulceration or kidney disease, or even the potential increased cardiac risk that older patients may have with those medications. So I'm a little bit more careful when using those.

There are topical over the counter arthritis creams and pain-relieving creams that I often recommend and the physical therapy. For rotator cuff disease, if I know there's a tear of the rotator cuff, I really try my best to stay away from cortisone type injections. We do have some evidence that can further contribute to difficulty with the rotator cuff after it's repaired, potentially the re-tear rates might be higher if you've had a number of cortisone shots. So I typically start with physical therapy, topical medications. Ideally, if the person doesn't get better, I might order an advanced imaging study like an MRI. If there's no tear, then I'm happy to continue with conservative management. If there's a small tear, then we have the discussion about continuing with conservative management versus maybe considering a shoulder arthroscopic procedure to repair it. And if it's a larger tear, then that's a different discussion because if it's a large tear and someone has not gotten better with therapy, then it would be a stronger recommendation for me to repair it.

Host: Do rotator cuff repairs, or do rotator cuff tears heal themselves at all doctor?

Dr. Erwetman: You have different types of tears. So if you have a low grade partial tear, it can scar over and feel better over time. If you have a large retracted tear where the ends are not opposed, you know, it's unlikely that it's going to heal itself. They might have an improvement in their symptoms, but it doesn't mean that the tear has healed. So it really depends on how large the terror is, whether it's a partial or complete tear. And I tend to think that a full thickness retracted tear doesn't have the ability to heal because the ends are nowhere near each other. And so that doesn't seem likely that would happen.

Host: So I know we're talking about many different types of shoulder conditions and certainly it's all based on whichever one that it happens to be, whether it's an arthritic condition or a rotator cuff disease, any of these things, do you find that some of the other modalities, because people want to know if there's things that they can do, do you like bracing? Do use ice or heat? If someone is a weekend warrior, if they're a golfer, if they play tennis and they start to develop this shoulder pain, what would you like them to do?

Dr. Erwetman: I think there's nothing wrong with using a little heat to warm up before exercise and ice if you're sore afterward, I tell people that if it helps them symptomatically by all means do it, but it's not going to really change their condition. A lot of the things that we do that don't involve surgery are really treating the symptoms and making something more tolerable for someone. So if that helps them, they should use it.

Host: I agree with you there. So tell us when the discussion, I mean, you are an orthopedic surgeon. When does the discussion for shoulder injuries become the discussion of surgery and what does that look like for patients? Tell us just briefly about the various procedures that you can perform for the shoulder that can either help repair or replace.

Dr. Erwetman: Right. Probably most of our listeners are going to be ones that have either arthritis or rotator cuff tears, and probably fewer listeners would be the young athletic population with dislocations. So to focus on the rotator cuff injuries and the arthritis, I almost always start conservatively unless it's a very large traumatic tear of the rotator cuff. In which case you probably want to fix that sooner rather than later. For arthritis, I always start conservatively with topical creams. We talk about the possibility of cortisone injections. And I tell people if you can manage these symptoms and have a good quality of life conservatively within the recommendations, which are really no more than a few cortisone shots a year in that joint, then you're doing well and we should continue and stay the course. Once the person has a hard time with conservative treatment, with regard to their quality of life and the things that we have available to us are not helping them anymore as much. Then we start talking about the option of shoulder replacement. With regard to rotator cuffs, I often try physical therapy first, and I like to see people back somewhat frequently. So if I send someone to therapy, I like to see them back in about four to six weeks or at the very least communicate with them in some way. If they're feeling like they're improving with therapy, then they can continue. If somebody is getting worse or not improving at all after four to six weeks of therapy, we have the discussion about surgical options.

Host: Well, thank you for that. As we wrap up, Dr. Erwetman tell us, give us your best advice, really for prevention of shoulder injuries, how we can keep healthy shoulders, whether we play sports or whether we want to be able to lift things and be active, how do we keep healthy shoulders?

Dr. Erwetman: So, there is a genetic component of all of this that we can't control, but from the standpoint of what we can control when you're lifting things, especially overhead or away from your body, you've got to be very careful. So, you know, avoiding repetitive, strenuous overhead work would be probably the number one thing that would contribute to rotator cuff disease. Of course, that's a lot of times occupational and very difficult to avoid, but anytime you can use equipment to make that easier or ask for help, so that you're not straining as much with overhead work, that's preferred. You know, to make you a volume hospital in the rotator cuff arena, we treat everything for the most part arthroscopically, which I believe is nicer for patients rather than open incisions and more postoperative pain and stiffness potentially. And from the shoulder replacement standpoint, we use the newest technology out there, which we didn't touch on as much, but the preoperative planning component. So using advanced imaging to get a 3D reconstruction of the shoulder and placing all of the components of a replacement on the bones of the shoulder, on the computer first, and being able to anticipate any potential problems that may come up before entering the operating room is the biggest advantage. And so that's how things are done now at Temecula Valley Hospital.

Host: Thank you so much, Dr. Erwetman for joining us today. What an interesting joint the shoulder is. And there are so many things, but you've given us a lot of good information and advice to keeping healthy shoulders. So thank you again. You can also head over to our website at TemeculaValleyhospital.com/services/orthopedics for more information, and to get connected with one of our providers. That concludes this episode of TVH Health Chat with Temecula Valley Hospital. Please remember to subscribe, rate, and review this podcast and all the other Temecula Valley Hospital podcasts. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. I'm Melanie Cole.