Joey Wahler (Host): It can hurt quality of life, so we're discussing shoulder pain in seniors. Our guest, Dr. Osama Elattar. He's an orthopedic surgeon for Wood County Hospital. This is Health Matters: Insights from WCH Medical Experts. Thanks for joining us. I'm Joey Wahler. Hi, Dr. Elattar. Welcome.

Osama Elattar, MD: Hello. Thanks for having me.

Host: Great to have you aboard. So first, from your experience, just how big a problem is shoulder pain for seniors specifically? And why is that? Is it just age and deterioration or is there more to it than that?

Osama Elattar, MD: Yes. When it comes to shoulder pain in elderly, and by elderly here, we mean people who are like above 60 or maybe even above 65, we need to first understand how the shoulder joint works, what's the structure of the shoulder joint to be able to isolate what types of problems happen in elderly people. So if we look at the shoulder joint, you will see here that we have the shoulder joint proper, which is basically the head and the socket, and you guys can see here the head and the socket is inside. There is the other joint on top of the shoulder joint, which is here. And this joint is formed basically by the collarbone meeting the shoulder blade. And surrounding that shoulder is a group of tendons that basically rotate that shoulder and cuff that shoulder. That's why they are called the rotator cuff tendons. This is a group of four tendons, one in the front, one on top of the shoulder, and two in the back of the shoulder. Those four tendons basically cuff the shoulder, keep the head inside the socket during motion, and add stability to the shoulder. So, basically, when it comes to shoulder pain in elderly patients, we know as we age that two things can happen in the shoulder. The tendons can start getting weak from wear and tear over the years, and similarly, the cartilage can also start wearing over the years, leading to what we call osteoarthritis. So basically, by the tendons weakening and getting used and abused over the years, what happens is, even without trauma, patients who are above their 65 can develop what we call atraumatic rotator cuff tears, the tendon rips from the attachment.

Similarly, patients can develop cartilage wear and tear over the years, especially we see it in patients who have been involved within kind of high level, high intensity work involving physical work, like lifting, like reaching excessively overhead, like pushing and pulling heavy stuff constantly. We also do see it in painters and carpenters, those kind of people who do manual work.

So, there are other sources of shoulder pain that can happen in elderly people. Here, between the tendon and the bone, we have something called the bursa. That bursa can simply get inflamed with some sort of repetitive overhead movements or repetitive activities. Also, there is something called the biceps tendon, which runs right there, and that also can be inflamed with sort of overuse or repetitive activities.

So basically, rotator cuff tears, shoulder osteoarthritis, cartilage wear and tear, bursitis, and biceps tendonitis, those are kind of the main problems that we do tend to see in elderly people.

Host: So for me, doctor, the interesting takeaway from what you said there is the fact that if you did manual labor, you mentioned painter, carpenter, contractor, et cetera, maybe you don't suffer any pain or an injury during your career, but it could catch up to you later, huh?

Osama Elattar, MD: Exactly. That's exactly right. And honestly, around here in Wood County, we do see tons of farmers. This is most of my shoulder practice. Farmers, over the years, they didn't really have any significant injury. Just like you said, it catches up to you later in life after you have used and abused a shoulder.

Host: Gotcha. So, if you have any of those above conditions, initially, what are you going to feel? What are the symptoms? I would imagine pain is on the list, right?

Osama Elattar, MD: So basically, one thing we do is history taking, right? And when we take history, little details can help us decide what exactly is happening with the shoulder. If there is history of injury or trauma, that makes it easy because usually with trauma or injury and with how the tendons are weak, we can basically diagnose rotator cuff tear even just by clinical exam. But usually, patients with shoulder issues share common symptoms. I will try to combine the symptoms so it can be simpler for people who are listening.

So basically, pain is the initial symptom. With time and as the pathology progresses, it becomes more of night pain that wakes them up during sleep. They have difficulty sleeping on the affected side. Even worse, if they have issues with both shoulders, it becomes difficult to even sleep on either side. Then, as time goes by further, those patients will have difficulty doing activities of daily living, such as reaching overhead, reaching shelves to get stuff, brushing their hair, reaching behind to clean. Simple tasks can become challenging to those patients as the pathology progresses.

As time goes by, the motion deteriorates and patients start having limited range of motion, especially in certain directions. And eventually, they might even have what we call pseudoparalysis. Sometimes the patients present with what we call pseudoparalysis, which looks like they are paralyzed. They are not actually, they are just unable to lift that arm above their head. So, pain, limited motion, and stiffness is what we commonly see in patients with either rotator cuff tears or shoulder osteoarthritis.

Host: So, that being said, when you first see a senior patient with these symptoms, how do you go about diagnosing what they have in particular?

Osama Elattar, MD: Proper history-taking, paying attention to every little detail, even minor trauma. Because again, those tendons are weak, they don't need much to rip. So, even minor trauma can be helpful in history taking. Also, besides the focused physical exam of the shoulder, we very well examine the neck. There is very common combination of neck and shoulder pain. We see it very frequently. We do a very meticulous neck exam, make sure there is no pinched nerve in the neck contributing to the shoulder pain.

There is also another part that we worry about, which is nerve entrapment. Some patients have nerve entrapment somewhere in the upper extremity, like carpal tunnel, cubital tunnel. We also pay attention to any tingling and numbness in the forearm and the hand, because that can help us in diagnosing concomitant pathology with the shoulder.

Host: And so, what would be the different treatment options these days for these various disorders?

Osama Elattar, MD: Well, first of all, deciding what kind of problem they have, we start with a very simple x-ray, which we have in office. And by getting an x-ray, it's basically a very easy and quick screening tool. We tend to rule out severe osteoarthrites. We can see it easily on x-ray. We can rule big stuff like tumors. Some patients have tumors. Some patients have history of cancer, have metastasis. We can see those things on x-rays. We can see calcifications in the tendons. All those things can be ruled out with a simple x-ray. If on x-ray and by physical exam, we are suspecting something with the soft tissues, with the tendons or the cartilage, that's when we tend to get further imaging studies such as MRI. MRI is very accurate, very sensitive. It will show us much more information, especially when it comes to diagnosing rotator cuff tears, biceps tendon issues, cartilage abnormalities. That's when MRI comes in action.

There is also other studies that can be used in certain situations, including ultrasound, CT. Some patients cannot get MRIs because they have claustrophobia, or they have some sort of metal that does not work well with the MRI, that's when we can get other studies such as CT and ultrasound.

After diagnosing what kind of problem the patients come with, treatment is always tailored. Tailored to the type of pathology, type of tendon tear if they have one, whether it's partial thickness, full thickness tears, patient age and activity level, and if they have any concomitant comorbidities such as diabetes, significant heart issues. Almost always, in pretty much every patient, we try to avoid surgery initially. Some patients are afraid to come to doctor's office because they think they will be offered surgery from the get-go.

With shoulders, it's almost always non-surgical management in the beginning. And it can be as simple as activity modification, limiting the triggering events. Anything that you know that can trigger your pain, you can avoid it. Simply bringing things from over shelf to your reach, right? So, you don't have to excessively reach can be an activity modification. For example, playing golf and it triggers pain, you might have to stop for a while until we control your symptoms. It's always much more than just activity modification. We try to use oral anti-inflammatories. We can use oral steroids. And then comes the workhorse for shoulder conservative management, cortisone shots. Cortisone shots are a very helpful tool. They pretty much can treat any problem in the shoulder. If you have a partial thickness rotator cuff tear, it can help. If you have osteoarthritis, it can help. Bursites, it can help, biceps tendonites. We can inject any of those structures and make your shoulder feel better.

Host: What would you say of all those conditions you've mentioned, what's the most common one you see?

Osama Elattar, MD: I would say 50/50 between rotator cuff tears and shoulder osteoarthrites. Sometimes there is an overlap too. Like some patients who have chronic rotator cuff tears. They have left it for years and years to the point that it became massive, retracted, and not even amenable to repair. They develop osteoarthrites, because the head is not cuffed in the socket. So, it keeps hitting every time it moves, and they develop cartilage disease as well. That's the worst combination, when you have osteoarthrites with chronic rotator cuff tears.

Host: Gotcha. And if you have osteoarthritis, doctor, I presume that can't be cured, right? But it can be basically managed, lessened, et cetera, right?

Osama Elattar, MD: Well, again, when it comes to osteoarthrites, the initial treatment is the same. We try to do activity modification, oral anti-inflammatories, corticosteroid injections, steroid shots. And then if this fails, comes the discussion about shoulder replacement.

Host: So, what would you say the latest advancements in surgical procedures for senior shoulder health looks like?

Osama Elattar, MD: Basically, there are two types of osteoarthrites. The type that we see the most is osteoarthritis secondary to chronic rotator cuff tears. So, patients who have had chronic tears, they neglected those tears over the years, develop osteoarthritis. So, basically, they have severe bone-on-bone osteoarthritis, and they have chronic rotator cuff insufficiency.

Back in time, before 2004, there was one type of shoulder replacement. That type of shoulder replacement was basically replacing the socket with a socket and replacing the head with a head. Back in time, they found that patients who have chronic rotator cuff tears, if you do that procedure for them, they do not do well. The pain goes away, but the shoulder does not move, because there is no tendons. The tendons have been chronically and massively torn. That's why some brilliant French surgeon back in 1984 came up with the idea of reversing the shoulder.

Reverse shoulder replacement has been done in Europe since 1984. It came to the States in about 2005. Reverse shoulder replacement basically relies on reversing the anatomy of the shoulder, where basically you put the head in the socket and you put the tray down. So, it becomes more of a reversed shoulder. That reverse shoulder replacement does not need the rotator cuff to move. It needs the deltoid muscle, which is the muscle that we all have on the outside of the shoulder.

Basically, it changes the mechanics of the shoulder, so it bypasses the need for the rotator cuff, and it allows you to gain motion despite having no rotator cuff. The advances in shoulder replacement have been amazing over the last 20 years. Now, we have what we call patient-specific shoulder replacement. So, pretty much every patient in my practice gets a CAT scan.

That CAT scan gets sent to the company that makes those instruments, and the engineers would basically play with the CAT scan, use those cuts, and come up with measurements. So, we go in knowing what size head, what size tray, what size stem, what size sphere, that guarantees the best possible functional outcomes and best possible range of motion for the patient. It kind of eliminates human error.

Host: With that being said, how much better are the results with this procedure as opposed to, say, 20 years ago?

Osama Elattar, MD: Much better. Much, much, much better. Patients are very happy. One thing I need to mention here is realistic expectations. I always tell patients after shoulder replacement, we are not doing shoulder replacement for you to go carry 50, 60 pounds. It's done to improve quality of life and to be able to enjoy activities of daily living with no pain. And I can claim, in two years in Wood County now, two and a half years, there is no single patient who failed to achieve those two goals. Pain-free, range of motion, and enjoying activities of daily living with no pain.

Host: So, being able to enjoy activities of daily living, yes. Joining the Olympic team for the next Olympic games, probably not so much, right?

Osama Elattar, MD: Exactly. We have to set expectations right. That's when the best outcomes happen, when patients are aware of the limitations and restrictions. They can golf, they can do what they like to do, it's just not for heavy labor, basically.

Host: Gotcha. A couple of other things. How about the expected recovery time for these procedures? What does that look like?

Osama Elattar, MD: Well, one thing I also need to touch base on before discussing recovery is rotator cuff tears. Because, again, back in time, rotator cuff tears, the standard was to do them open. It's an open surgery, it's a big incision. We do not do open rotator cuff repairs, which means that basically, through minimally invasive surgery, where you basically have five-step incisions, each one one centimeter, five holes is all we need. We stick a camera inside the shoulder and we're able to fix any tendon tears through arthroscopy with anchors that basically anchor the tendon back to the bone. That, in terms of recovery, when it comes to rotator cuff tears alone is very important because, again, we avoid big incisions, we avoid splitting muscles, it's less morbidity for the patients, and that does speed recovery for patients.

Recovery from shoulder surgery takes anywhere from 8 to 12 weeks. There are patient factors, which is basically every patient is different when it comes to pain. We always tell patients when it comes to physical therapy, you have to push through some pain within reason, of course. So, recovery is about eight to 12 weeks. It can take a little bit longer in some patients. But at the end, everybody achieves goals. Usually by six months, everybody's fully recovered and have no pain.

Host: That's awesome. So in summary here, doctor, generally speaking, obviously you've covered a ton of ground here, did a great job explaining it all. What's your message for seniors listening and watching about the chances of effectively addressing their shoulder pain?

Osama Elattar, MD: My advice is do not wait because "I'm worried about going to the doctor. It's probably going to be surgery." It really does not have to be surgery. We can really manage your shoulder pain with activity modification and some injections. And even worst-case scenario, if surgery happens, the advances have been shocking over the last 20 years. Recovery is not as bad. We have very good pain management protocol postoperatively. And we always try to achieve patient goals and, again, set expectations right, which makes everybody happy.

By waiting, if it's a small tendon tear, you are risking getting a massive tendon tear that becomes difficult to repair. I'm just giving an example of what waiting can do. If it gets to the point where it's massive, not repaired, instead of a simple minimally invasive surgery, you are talking about a shoulder replacement. And even when it comes to shoulder replacement, instead of a straightforward shoulder replacement, if you let it go for years and years until it gets to the point where it's bone and bone, and the head is eroding into the socket, you are adding complexity and difficulty, where you might need custom implants instead of the standard implants that we use.

Host: So, the bottom line there is even if you're scared, as you say, about going to the doctor in the first place, what you could be looking at if you wait will be a lot scarier, right?

Osama Elattar, MD: Exactly, exactly. That's exactly the way to put it.

Host: Well folks, we trust you're now more familiar with shoulder pain in seniors. Dr. Osama Elattar. We appreciate the show and tell. Thanks so much again.

Osama Elattar, MD: Thank you so much. I appreciate the opportunity. Thanks for having me.

Host: Absolutely. And for an appointment with Dr. Elattar, please call Wood County Hospital's Advanced Orthopedics Department. They're at 419-354-3072. Check out Wood County Hospital's other podcasts on your favorite way to listen to podcasts. If you found this one helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being part of Health Matters: Insights from WCH Medical Experts.