Shoulder Pain: Treat It and Beat It

Intro: This is Weekly Dose of Wellness brought to you by MemorialCare Health System. Here's Deborah Howell.

Melanie Cole (Host): The most movable joint in the body is the shoulder and it's also potentially the most unstable joint. My guest today is Dr. Ari Youderian. He's a board-certified orthopedic surgeon who specializes in the care and treatment of complex injuries with Saddleback Memorial. Welcome to the show, Dr. Youderian. Tell us a little bit about the shoulder. It is a complex joint, it has so many movements. How come things can go wrong and what generally goes wrong with the shoulder?

Ari Youderian, MD: Yeah, well, there's a lot of things that go wrong. Thanks for having me, by the way. I always tell people all shoulder pain is not the same. And like you mentioned, there are many layers of the shoulder, including the bony and cartilage layers, the tendon layers, the ligaments in the shoulder, and so on. The more common injuries that we see are often related to something we classify as impingement, but really that means things such as bursitis, which is an inflammation around the shoulder, tendons, rotator cuff tendonitis or tears we see very often, and even something called a frozen shoulder is not an uncommon thing that we see. These all affect different areas of the shoulder. Like I mentioned, sometimes it's the tendon that actually tears where that connects to the bone, or there is inflammation around the tendon, and again we call that bursitis. These are the more common things we see, but then the list goes on and on, such as fractures and arthritis causing pain.

Melanie Cole (Host): So with the shoulder joint, and being this complex joint, when somebody feels a little bit of shoulder pain, what do you tell them as a first line of defense if they just start to feel some pain before they need to really maybe go to physical therapy or see a doctor?

Ari Youderian, MD: Yeah, so often people will try other methods before coming to see a surgeon or even doing some therapy. Obviously it depends on the injury. The caveat is obviously if there's an acute injury, meaning something you fall or you get hit by something, or a sports injury where you felt a major tear or crack or pop, then that sort of sets into one category that typically would need to be evaluated earlier. But if it's just sort of a chronic achy thing or soreness after working out, we typically do recommend anti-inflammatory medicines over the counter. A little bit of rest always helps. A few days, sometimes even a couple weeks it takes in the shoulder for little things to settle down. Home applications of icing or heating typically do work as well. But when those start trailing, that's when we, or those start failing rather, or not working, then that's when we often recommend seeking additional care.

Melanie Cole (Host): So one of the most common injuries would be rotator cuff injuries. You mentioned a little bit. Is this something that comes naturally with age? Is everybody susceptible to a rotator cuff injury?

Ari Youderian, MD: That's a tricky question actually. In general, the rotator cuff does degenerate with age, which means that it does have a blood supply that tends to decrease over time, and the tissue quality does thin out and become weaker over time. So it doesn't mean that everyone is going to get it, but it does mean that a high percentage of the population can have rotator cuff tears and or injuries as they get older, and they are definitely more susceptible to them as they're older. What we see is in our population now where people are very active in their sixties, seventies, even eighties, whether it's playing golf or I see people that are lifting weights and bowling and doing all kinds of classes in these higher age groups, that they definitely have a higher propensity to have an injury simply because of age and degeneration alone.

Melanie Cole (Host): Do rotator cuff injuries, whether it's a micro tear or just inflammation, do these go away on their own?

Ari Youderian, MD: They sometimes go away on their own, but they sometimes do not, and it's hard for us to predict which ones will and which ones will not. I would say that giving it a little bit of time does not hurt, meaning doing those things we mentioned earlier, some of those home treatments and seeing how that goes for a few weeks is not necessarily a bad thing because some of them will go away, but there is a percentage that do not.

Melanie Cole (Host): So when the symptoms start to affect the quality of life, putting on their coat, pain at night, any of these things, when they come to see you, what is the first thing that you do with them?

Ari Youderian, MD: Well, we often take an X-ray actually, just to look at the overall picture of the joint and the bones to see if there's anything chronic or new injuries. Before even the X-ray, I guess I should mention is we do a full history and physical exam. And on our history we ask those simple questions like when does it bother you, what types of activities are really giving you the most trouble, are you having pain at night, which is often a sign of the rotator cuff being affected. And then we try to piece all those things together to come up with the diagnosis.

Melanie Cole (Host): And then once you have diagnosed somebody, where does a cortisone shot fit into that treatment?

Ari Youderian, MD: I would say that depends on the injury and the age of the patient and also their goals and outcomes. There's a lot of factors that go into that. A steroid or cortisone injection is useful to help decrease inflammation and to help stop or block the pathways of inflammation. So if we see a condition such as bursitis or rotator cuff tendonitis in the shoulder, and in addition arthritis, those are three common things that we do use steroid injections for. We often try to do non-invasive treatments first, prior to giving an injection, such as therapy and home exercises and other oral medications, but they definitely come into play in people that have several months of pain and are very uncomfortable, specifically having night pain or things that are really inhibiting their activities.

Melanie Cole (Host): How often can someone get a cortisone shot?

Ari Youderian, MD: We usually say it's about every three to four months. So roughly three or four in a year in the same location, the same exact type of injection would be reasonable. But you can get more than that if you're putting them in different areas or different body parts.

Melanie Cole (Host): So Dr. Youderian, when would surgery necessarily be something that you start discussing with a patient?

Ari Youderian, MD: So that depends on the diagnosis. If you have an acute injury, meaning someone that has a full tear of their rotator cuff from an accident or injury, someone that has a fracture or end-stage arthritis, if you will, that kind of goes into the surgery category more quickly. But everyone else, you basically treat in every other way you can. Give them the therapy and injections and all the other things we mentioned earlier, but if it's not working or it works for a short period of time and then returns, that's when we think surgery could be a reasonable option.

Melanie Cole (Host): What do you like patients to ask you doctors about shoulder surgery?

Ari Youderian, MD: I think it's important for them to know what they're getting into. Specifically, what the expected... a lot of people ask about the length of the surgery itself, which is somewhat useful, but for me it's more what happens once they wake up and they're aware of what's happening. So, asking about the recovery phase, what's involved, how soon does physical therapy start, how long will they be wearing a sling, or will they not be able to use their arm? And specifically asking what it's relevant to them personally. Meaning, let's say someone is a teacher and they need to get back to school teaching, they want to know specifically, okay, what can and can't I do? Can I write on the chalkboard with my hand overhead, or am I going to be stuck using an overhead projector and just writing close to my body. So questions that are specific to what they want to be doing and asking when and at what point in time they'll be able to do those things. Those are often some good questions.

Melanie Cole (Host): And do you have any tips to give the listeners of ways to prevent and protect your shoulder from injury?

Ari Youderian, MD: I do actually. It's a little tricky. Like we mentioned on one of your first questions regarding age and is everyone susceptible to some of these injuries, sometimes you can't prevent them. But we do know that there are some associations with rotator cuff injuries and other conditions in the shoulder that are related to cholesterol levels and overall health conditions. So maintaining a healthy lifestyle just like everything else, maintaining a good diet and routine exercise in general will keep your muscles and tendons and body parts in a good condition that either can prevent it or at least if you sustain injury can potentially heal better. I always tell patients with shoulder specific problems that maintaining a good posture is actually very important. So when your mother used to yell at you to sit up straight, that actually helps because it keeps your shoulder in a more neutral position and puts less strain on some of the tendons around the shoulder, specifically the rotator cuff. So that's always beneficial if you will. And lastly, there are some specific shoulder or balancing strengthening programs to balance the muscles about the shoulder. So when people are working out, we often recommend they make sure they're working out muscles in the back and the front and the side of the joint so you're not keeping it in any type of imbalance.

Melanie Cole (Host): Thank you so much, Dr. Youderian. It's really great information. You're listening to Weekly Dose of Wellness with MemorialCare. And for more information, you can go to memorialcare.org. That's memorialcare.org. This is Melanie Cole, filling in for Deborah Howell. Thanks for listening.