Caitlin Whyte (Host): Shoulder pain can be such a hassle and quite frustrating to live with. So we are joined by Dr. Anthony Villare today for an episode on dealing with shoulder pain. He is an Orthopedic Surgeon at Upland Hills Health in Dodgeville. This is the Inspire Health Podcast from Upland Hills Health. I'm Caitlin Whyte.

We are talking all about shoulder pain here, so can you tell us about what you see? What causes shoulder pain, weakness, or loss of mobility, and what are some of the different types of shoulder problems you see in patients?

Anthony Villare, DO: First of all, I should preface it by saying the shoulder is a very complex joint. That's why we can throw a football and throw a baseball. It's not like any other joint. And mainly because it's strength, it's mobility, all comes down to the muscles and tendons that surround it. And there's a lot of them. It's a ball and socket joint with cartilage and bone just like everything else, but it really relies on the soft tissues around it for its stability, its function, its mobility, and when you talk about all those muscles and tendons and ligaments all working together, it's like listening to an orchestra and they're all playing the same sheet music. As we get older, as we start going through life, maybe getting a little injury, maybe sleeping in a funny way on one side or something, you know, we can get shoulder injuries. Now, part of that orchestra is maybe playing in a different tune, and then it can sometimes snowball to where all the muscles and all the tendons are not functioning properly.

All the band members in that orchestra are all playing a different tune, and it sounds horrible, and that is basically equivalent to the pain you have in your shoulder. It's when there is a mechanical and functional mismatch, the muscles aren't functioning right. It doesn't always mean arthritis doesn't always mean a break, doesn't always mean instability. It just means that all those muscles and tendons are not in sync and functioning properly. I don't think we have enough time to really talk about all the shoulder problems there are. I'd say, you know, like it's a joint and it can wear out like any other joint. So arthritis can be a problem. The most common problem would be what we call impingement syndrome, which is a combination of a bit of weakness in the shoulder combined with overuse of the shoulder, or continued use of the shoulder without being aware that, you know, it might be a little weak, it might not be able to handle the task that you're making it perform.

And that leads to a little bit of a sloppy motion in the shoulder, which can lead to bursitis, which is an inflammation of a cushion of tissue in the shoulder. And it could also lead to tendonitis, which is an inflammation and irritation of the rotator cuff tendons around the shoulder, that's probably the most common. It's painful. People can misinterpret it as like, wow, something's really wrong in here. You know, we might get an X-ray and an MRI and it doesn't really show much, but it's still a problem because it's all the soft tissues aren't working right? You can have a rotator cuff tear. That's probably the other most common thing. Those tendons and there's four rotator cuff tendons, and if you tear one of those, it doesn't heal on its own with just rest. A small tear becomes a big tear and then a big tear without treatment, and in these kind of cases, it's surgery to repair the tear. Those big tears can scar down, retract, and then they become irreparable tears. And then that can be a real problem because now, like you're driving a car with one flat tire, you know, it's like, yeah, you're going to go, but you're not going to go far or very fast. Shoulder symptoms can be a real problem.

Host: Absolutely. I've heard about all kinds of crazy things, so I'm glad we're talking about this topic today. Is there anything patients can do to start at home to reduce pain and improve function when they're starting to feel some issues in their shoulders?

Anthony Villare, DO: Oh, sure. I mean, aside from, you know, having sustained any kind of significant injury, if they just start to notice some shoulder pain and there's been no trauma, no history, you know, you didn't help a neighbor move a refrigerator up two flights of stairs, you know, that kind of thing. Always make sure, number one, can I move it, is it stiff? And you, you might say, well, how, how do I know what my shoulder motion is? Well, compare it to your other shoulder, and if you're not sure there, I hate to use the internet and Dr. Google, but you know, sometimes you can find out on the internet what is the normal range of motion for a shoulder.

And then you can kind of do your own, your own self-assessment. Is it stiff in this direction or this direction or rotation or whatever. A stiff shoulder can be painful, period. It could look completely normal on an MRI and an x-ray, and it could still be painful because it's stiff. It's what we call frozen shoulder.

 And until you get that shoulder loosened up and limbered up, until you've regained full motion in that shoulder, you could have pain. And that's aside from all the tendonitis and rotator cuff tear and arthritis you might think you have. First thing is regain and maintain and make sure you have full range of motion to that shoulder.

And then the next thing is it make sure it's strong, or you have good muscle tone there. I mean, we all can't be strong like, like an NFL player and stuff, but that's something to assess. I know when I exercise, if I fall off my exercises and my shoulder starts hurting and then I go back to my exercises, my shoulder doesn't hurt anymore because I'm toning up all the muscles around my shoulder, not just the rotator cuff, your deltoid, your biceps, your triceps, you know, all these muscles, your upper trapezius going to your neck. All those muscles play a role in how your shoulder feels. So you want to make sure that you can not only move it, but those muscles are all toned and working properly, because that's all going to lead to a stable shoulder.

Host: Of course. So when does surgery come into the picture? When do you know at home treatments maybe aren't doing anything, aren't really helping, and then someone goes to a doctor. What would be like the next step of treatment?

Anthony Villare, DO: Well first aside from an MRI showing a rotator cuff tear, cause those almost always need surgery to be repaired. You can't do that with therapy and all that. That's one way to, let's say, need surgery on the shoulder. Another way is and I'll use impingement syndrome as an example.

Let's say, you've tried avoiding overhead work with the arm. You went through physical therapy, we've tried cortisone injections. If we've done all that and that's not enough to relieve you of the pain that you're having in your shoulder, then we'll probably get an MRI somewhere through that, we'll get an MRI of your shoulder. And a lot of times it's the bursitis or might have built up a spur of bone or something that's kind of pinching the tendon off. That would be a reason to do surgery. Even if the MRI doesn't show that much, if it doesn't show any kind of obvious or significant pathology, sometimes impingement syndrome with that scenario can get better, but you need surgery to help get it better.

 You've built up too much scar tissue in the shoulder. That spur of bone just keeps aggravating it. So in surgery, and it's arthroscopic, we're not opening the shoulder up at all. These are all through many incisions. Through those incisions, we can not only assess what the shoulder joint itself looks like, but we can assess the tendons around it and what condition they're in, we can clean out and remove any of that built up hypertrophic, scarred up bursa that is just aggravating your shoulder. Clean that out. Go to a fresh start. We can level off that spur of bone, take it away with small instruments that we put in the shoulder, basically sort of, we call it a cleanup job.

 But we can do that and then let you get off to a fresh start. But even after that surgery, the surgery isn't the answer. Therapy is still the answer. And, and that's one thing I always explain to a patient. Surgery is a tool we can use to help explain and remove or fix, explain why isn't this patient getting better with just therapy? Because therapy, is, in my book, always the answer for a shoulder problem.

Even if we do surgery, you got to go to therapy afterwards. So if therapy wasn't working before, why not? What's going on in your shoulder that's preventing you from getting better with just therapy? So we need to do surgery. Go in there, either fix it or remove it, so then you can go back to therapy and get better. Follow me?

Host: Absolutely. And as we wrap up this episode, Doctor, I just want to ask one more question about joint replacement. Is it possible to replace the shoulder joint as is done with knees and hips?

Anthony Villare, DO: Yeah, absolutely. And, and our knowledge of joint replacement of the shoulders is improving all the time. Ten years ago, we didn't have, well, first of all, we didn't even have the concept of the types of joint replacements we can do in shoulders. Shoulders can wear out just like any other joint. It does start to wear out in a unique way.

If you have a chronically torn rotator cuff tendon, meaning like years and years of a torn rotator cuff. Now in years past, we couldn't really treat patients much with this, with a joint replacement. Now, we have options. So let's say you have a worn out shoulder. It's there. It's on x-ray. It's obvious. If you have a rotator cuff intact, rotator cuff tendons around the shoulder, we can replace it. We can do a shoulder replacement, ball and socket replacement just like you do in a knee or a hip, you know? And now you don't have that bone grinding on bone anymore. You have a nice, smooth round joint, gliding against another smooth surface. And there's still a lot of rehab to be had because there's still, again, all the soft tissue around it is key towards pain-free, stable functioning shoulder.

 There's another type of replacement if you have a chronically torn rotator cuff tendon. And that shoulder replacement is called a reverse shoulder replacement. And the reason we call it that is because, we reverse the ball and the socket joint. So your socket is usually part of your shoulder blade.

When we do a reverse shoulder now, we put a ball there and where the ball is in your upper arm becomes the socket. And I don't know the history of who was the first person to be tested on this and whatever, but that has proven to give a patient a stable pain-free joint versus the other way, you know, a regular ball and socket swap off, with a joint replacement does not give a patient a stable, functional joint, but the reverse does.

So that's something we've learned. And shoulder replacements, reverse shoulders, total shoulders, I'm seeing more and more patients in my office and giving them those options. Again, there's still rehab with it, you know, afterwards. So even though we do it, it's pain control, but we got to get the shoulder joint moving, got to tone up those muscles, got to go to therapy afterwards. But there's definitely, patients don't have to live with stiff, painful arthritic shoulder joints nowadays.

Host: Well, always such a pleasure to have you on the show, Dr. Villare. Thank you again for joining us. Find out more about Dr. Villare and Upland Hills Health on our website at uplandhillshealth.org.

This has been the Inspire Health Podcast from Upland Hills Health. I'm Caitlin Whyte. Be well.