Watch this video of Ms Ruth Delaney, Consultant Orthopaedic Surgeon specialising in shoulder injuries at UPMC Sports Surgery Clinic.
This video was recorded as part of SSC’s Public information meeting focusing on Orthopaedics.
Hello and welcome to our evening discussing orthopaedic problems. Thank you for tuning in. My name is Ruth Delaney – I am a shoulder surgeon at UPMC Sports Surgery Clinic and I am going to talk about some common shoulder problems that we see.
My own background is that I’m originally from Cork and I then spent a lot of time in Boston doing most of my orthopaedic training, particularly at Mass General where I also did shoulder fellowship and got to spend time, as well as Boston, in France here in Lyon before coming back to Dublin in 2014, where I practice exclusively in the field of the shoulder.
Shoulder pain is really common – 70% of us are going to have shoulder pain at some time during our lives, and about a quarter of people who have shoulder pain, it’s not their first time having pain around their shoulder. Pain in the shoulder can lead to disturbance of sleep, which obviously has a major effect on the quality of life. It can make it difficult to keep up your normal work or your usual activities. Pain in and of itself around the shoulder is an important symptom. There are other symptoms that often present besides pain, and shoulder weakness, can be a feature of shoulder problems, even to the point of having difficulty raising your arm. Shoulder stiffness can also be a major issue, and unstable shoulders recurrent dislocations are something that we see quite a lot, particularly in the sporting population.
So when we assess shoulder problems. We take a history so we ask you questions that help us to figure out what might be the underlying diagnosis and a lot of times the pattern of your symptoms and certain things that aggravate or help them can give us a good idea as to what’s going on, and in certain cases even your own background medical history. Examining the shoulder is really important, it’s really helpful for us as we get a lot of information from actually examining the shoulder. Imaging sometimes is not even all that important, it may help us to confirm a diagnosis or to rule something in or out.
Depending on what your shoulder problem is – an X-ray might actually help us more than an MRI sometimes, so for things like shoulder arthritis, a certain type of tendinitis where there can be calcium deposits in the rotator cuff so calcific tendinitis and those things are actually seen better on an X-ray. So our AC joint or acromioclavicular joint problems. Sometimes even if you already have had an MRI – we may need to go and get an X-ray.
For some things, MRI can be helpful. Sometimes there are other studies that we’ll get like for example CT scans in certain situations. If there’s shoulder arthritis and we want to plan a replacement or if there’s a fracture.
|Four of the most common diagnoses that we see with shoulders are rotator cuff problems, frozen shoulder, shoulder arthritis, and shoulder instability.|
So some of those problems sometimes lead to consideration of shoulder surgery. But there can be a lot of different rumours out there and a lot of misinformation. So, if a shoulder problem is at the point where shoulder surgery is becoming a consideration – I think it’s really important to get advice from a shoulder specialist.
Because shoulder is a fairly rapidly evolving field, there’s a lot of recent knowledge there and sometimes even with the best will in the world, other people be it laypeople or even healthcare professionals may not have an in-depth understanding of your particular shoulder problem.
When we’re considering surgery for a shoulder problem, we will help you look at the risk/benefit balance in your individual case. Also important to consider the recovery and rehabilitation period involved after a surgery for your own lifestyle, your work, what you need to be able to do, and so you have the right expectations going into a procedure as to how long your rehab afterwards might be. Preparing for shoulder surgery is important too from a practical standpoint, if you’re going to be in a sling for a little while afterwards, that will mean that you can’t drive it will mean that you will need help at home in terms of preparing meals even getting dressed and undressed. So all of that needs some thought beforehand.
Also if your shoulder for example is quite stiff before surgery sometimes we’ll have you do some physiotherapy beforehand in order to make your post-operative recovery a bit easier so there can be quite a lot of thought and preparation that will go in before you even come as far as having surgery for a shoulder problem.
We are always adding to our website and trying to increase the amount of resources that we have available for our patients and their families in order to get more information about what to expect. For any shoulder condition, and for those that require surgery.
We also use something called surgical outcome systems for all our patients who are going to have shoulder surgery and this is based on the idea that all surgeries should have their results measured, so that we can report those results and be very upfront about them, and this comes from one of the first shoulder surgeons over 100 years ago, named Codman.
So everybody who has surgery will have the opportunity to be part of this email based system, and it will send questionnaires to patients at various time points during the recovery, and then we’ll be able to see where that patient is relative to the average both within my practice and also a global average which is very reassuring.
This is the team who work with me; Danielle heads up the administration staff, joined by Barbara and Lorraine. Orla’s our physio and our current fellow right now is from Belgium, Joachim, and later on this year we’ll have a French fellow taking his place.
So to go back to the main diagnoses that we’re going to look at today. Shoulder instability is something that’s a huge topic and probably a whole other talk on its own. So we’re going to focus mainly on rotator cuff, frozen shoulder and arthritis, but if anybody has questions about shoulder instability I’d be more than happy to discuss it during the question and answer phase.
Rotator cuff is something that you hear a lot about in terms of shoulders, and often every shoulder pain is blamed on the rotator cuff, which isn’t always necessarily true. The rotator cuff is a group of four muscles deep inside the shoulder. We can see them here from the front and from the back there’s one big one in the front, one over the top and two in the back.
Their job is generally to help elevate the arm and rotate the shoulder, and also to keep the ball cantered in the socket.
The tendons that attach those muscles to the humerus or the arm bone don’t have a great blood supply and they do undergo normal wear over time. They can also get inflamed which can lead to pain, and sometimes there can be full thickness tearing in the tendon where it detaches from the bone as we see in those pictures there.
The normal wear over time will often be seen on an MRI may not be the cause of the symptoms happening in the shoulder. It doesn’t need any treatments so things that you may see on an MRI described as tendinopathy, tendinosis, partial tearing – those are often normal age related changes and will often look exactly the same on a non-painful shoulder as on a painful shoulder when looked at on an MRI.
If rotator cuff inflammation or tendinitis is the problem we’ll often treat that with physiotherapy as a mainstay – sometimes we’ll use a cortisone injection to damp down that inflammation to allow you to engage with physiotherapy.
If there’s a full-thickness tear or detachment of the tendon – it doesn’t necessarily always have to be fixed it depends on a number of factors including the size of the tear, the age of the patient, the desired activity levels. So sometimes physiotherapy and injection will also be how we will treat some of the smaller full-thickness tears or the more gradual degenerative tears, as opposed to tears that are acute and traumatic – ones that happen suddenly if somebody falls down or something like that.
So in some situations, surgery will be the appropriate consideration for example if a tear is bigger, or in a patient who’s a bit younger.
If we do surgery to repair a rotator cuff, it’s done keyhole or arthroscopic, and we reattach the torn tendon to the bone as you see in those pictures using anchors that go into the bone and those have stitches or heavy stitches going through them which allow us to stitch the tendon back to the bone.
Even though it’s a keyhole surgery, it’s quite a bit of work on the inside and so the recovery process does take a bit of time and that’s an important conversation that we have before embarking on rotator cuff repair surgery.
After rotator cuff surgery, we use a shoulder immobilizer – it’s like a sling with a pillar which gives you a bit more support than a regular sling and takes tension off the repair, typically four weeks is the period of time that you spend in the sling but if the tear is large or the tendon is fragile we might use it for six weeks.
You can’t drive while you are in a sling – with the physiotherapy program is designed to support the repair and get your shoulder moving in the initial phases, and then later move on to strengthening but it’s important to know that it can take about six months to work through all of the rehab from a rotator cuff repair surgery. This is a video recorded a few months ago on what to expect for rotator cuff repair.
One of the most common problems that we see involves the rotator cuff. A lot of people aren’t sure what the rotator cuff is and basically it’s these four small muscles that are deep inside the shoulder, and they’re attached to tendons – tendons attaches the muscle to the bone, the rotator cuff helps keep the ball centered in the socket of the shoulder joint and helps the ability to raise the arm as well as obviously rotate the arm. The rotator cuff tendons don’t have a great blood supply so over time they often have wear and that’s pretty normal it doesn’t necessarily cause symptoms, it’s something that’s often seen on an MRI and may even be described as a partial tear. Sometimes that can lead to inflammation and pain and we can often treat that with injections and physiotherapy. But when the rotator cuff wears to the point where it fully tears off the bone, or if you have a trauma such as a fall and that causes an acute tear of the rotator cuff where the tendon actually detaches from the bone, then often that’s something that we do need to consider surgery for.
The problem is with the poor blood supply the tendons can’t actually heal themselves. So very small tears, don’t necessarily need to be repaired. So if one tendon has a little tear in it often the other tendons can compensate. Sometimes we’ll try physiotherapy to work on those muscles to compensate as well as the big deltoid muscle on the outside of the shoulder. But other times if the tear is a bit bigger, or if the conservative approach isn’t working, then we need to consider actually repairing the tendon back to the bone in order to get it to heal and to allow the shoulder to function better and to decrease pain.
With rotator cuff surgery, there is quite a lot involved and we have information leaflets that we will give to patients in order to help you to take in all of the information. Even though it’s a keyhole surgery, it is quite a bit of work on the inside, and therefore the recovery time is longer than what you might expect from a keyhole surgery.
So what the inside of a rotator cuff repair looks like at the end is pretty much this: this is an example of a reasonably large tear, we use these anchors in the bone that allow us to stitch the tendon back to the bone using these heavy sutures.
This takes a while to heal – that’s why after a rotator cuff repair the patient typically spends four weeks in a shoulder immobiliser – sometimes six weeks if it’s a very large tear or if it’s a tear that isn’t directly repairable and we have to augment it with a graft, but for most rotator cuff repairs, you’re talking about four weeks in a sling, the sling is a shoulder immobiliser with a pillow at the side like this, and that serves to take tension off this repair in the initial phases of healing.
Depending on the quality of the tendon and how large the tear was you might or might not be allowed to do some gentle exercises during that initial four week period. I’ll see you back in about two or three weeks, we’ll check that the sling is fitting you okay that your wounds are healing well, and that you’re ready to go on to the next phase of your rehab.
When you come out of the immobiliser at four weeks – the next stage is that you are allowed to actively move the arm. Up until that point we don’t want the arm moving under its own power because we don’t want to put too much stress on the repair.
Once you’re out of the sling, it’s all about regaining range of motion, up until about 12 weeks after surgery we don’t worry about strengthening. It’s too soon to try and strengthen the shoulder before 12 weeks, the rehab protocol is built around that and all of those instructions will be given to your physiotherapist so that they know how to design your exercise program.
Usually, we’d meet again at about 12 weeks before we start that strengthening phase, so that I can make sure that you’re making good progress with your range of motion and we don’t have any problems with stiffness before we start to move on to the strengthening phase. In terms of what you can and can’t do during the phases of your recovery, a common question is ‘when can I drive again?’ – you can’t drive when you are in a shoulder immobilizer, you’re not insured to do so even if you think you could manage with one arm so you absolutely cannot drive during that first four/six week period.
Most people find it takes them another week or two after they come out of the immobilizer to actually get comfortable to drive – from my point of view it’s okay for you to start to try to drive once you’re out of your shoulder immobilizer so typically four weeks for most tears six weeks for some of the bigger tears.
I always suggest that you try in an empty carpark or maybe your driveway before you go out on the road and drive.
In terms of work, it depends on what your job involves if you have a job that involves any heavy physical activity, then you’re probably going to need to wait until that 12 week mark before you go back to your full duties at work because the shoulder is not going to be anywhere near strong enough to take any stress.
If you have a job that does not involve any heavy lifting if you have for example a desk job, then you can often go back even before you’re out of your immobilizer once your pain is under control.
Rotator cuff repair can be pretty painful in the first couple of weeks but that does tend to dissipate quite quickly. We always make sure that you have a prescription for painkillers and we can adjust that as needed in those initial few weeks.
Typically recovering from rotator cuff repair takes on average about six months to have the shoulder back in good working order. And it’s important to understand that before you start on the process so that you’re aware of what to expect and the fact that sometimes it takes a bit of patience before you get there. We will always follow you closely and communicate closely with your physiotherapist to make sure that we optimize your recovery.
So moving on to the next category in our common shoulder diagnoses: Frozen Shoulder is something that we see quite commonly. It can be often misunderstood and the term frozen shoulder can often be applied to any shoulder that’s stiff and sore and that’s not necessarily true.
Frozen shoulder is a specific condition where the capsule of the shoulder joint – so the lining that in case of that ball and socket joint of the main shoulder actually gets inflamed so that’s an inflamed capsule or capsulitis. So it’s also called adhesive capsulitis.
It often happens for no good reason that’s the most common scenario, and it’s more common in certain groups, particularly in women in certain age groups and it can be associated with underlying hormonal conditions like diabetes, thyroid issues or around the time of the menopause, but it can affect anyone and particularly with the past year we’re seeing it a lot more commonly in just about anybody.
It can be very painful when it first starts the inflammation in the capsule causes a lot of pain, particularly with any movement of the shoulder. As that inflammation develops the capsule of the shoulder gets thickened and tightened the shoulder starts to get stiff it becomes very difficult to move the shoulder. It can be frustrating because you don’t really see anything on imaging. So again, examining the shoulder is the key to figuring this one out and having the right diagnosis.
An MRI will often just confuse things because you’ll see things that maybe aren’t actually relevant to what’s going on.
The pain is quite intense so arriving at the right diagnosis and starting treatment can be really helpful. If you were to do nothing at all with frozen shoulder, it would theoretically burn itself out, but that can take up to two or even three years. For most people, that’s just too long to wait around because it’s just too painful.
The problem is inflammation, so the strategies we use to hurry up the process of resolution are anti-inflammatory strategies, whether that’s non-steroidal anti-inflammatory medications and things like ibuprofen or some of the prescription things like maybe diaphine.
We also often use steroid, as a big term anti-inflammatories – so cortisone injections. It’s important that the cortisone injection is into the main shoulder joint because that’s where the capsule is.
A lot of times, people who are not shoulder specialists will inject shoulders, but they might not inject the main joint. And so sometimes patients come to see us who’ve already had injections and haven’t gotten any benefit, but they may not have just had the right spot injected yet – in patients who have a lot of pain will often use a short course of steroid tablets for just about a week or 10 days as well.
Sometimes it takes a second set of injections. But most people find that with injections and a gentle course of stretching, that the frozen shoulder does settle down. We don’t tend to use formal physiotherapy because somebody else pushing the shoulder and stretching it can often just aggravate it. So we give you a home stretching programs and videos to follow – what can be really helpful when they’re available obviously we don’t have the option right now is getting into a swimming pool and doing some stretches in the water so not actually swimming but just gently moving the shoulder in the water.
These are some pictures from the videos that we use this is Orla our physio showing you how to do some gentle stretching with the shoulder. This is something that you do yourself at home – only up to about 5 out of 10 discomfort no severe pain, no aggravating shoulder.
And I would say over 90% of frozen shoulder cases get better that way.
In a small number of cases, we might consider surgery, if things are not settling down. We do a keyhole surgery called an arthroscopic capsular release.
So it’s not a case of just blindly manipulating the shoulder the way that used to be done, it’s much safer to release the thickened capsule in a controlled fashion. We do this under general anaesthetic and we usually use a nerve block so local anaesthetic around the nerves that supply the shoulder and arm, and that helps with pain relief and it also helps with immediate physiotherapy afterwards in the hospital, because the arm is numb and so the physios can really stretch it.
The thing we want to avoid is the shoulder stiffening up again. So where we were being really gentle with it, when we’re treating without surgery, if we do end up having to do a release for frozen shoulder, then we need to start immediate physiotherapy straight away to stop them from getting stiff and purely for that reason will usually keep the patient in the hospital for one night so that they get immediate physiotherapy the afternoon that they’ve had their surgery and then again the following morning so we get a head start on range of motion.
This is what it looks like on the inside – a really red angry capsule of the shoulder joint and this radiofrequency device releasing the thick layers of capsule and restoring range of motion in the shoulder.
Another reason that a shoulder can be stiff and painful is arthritis. And the way we tell the difference between frozen shoulder and arthritis is principally by an X ray, because they can examine very similar. Usually the history will give us some clues as well.
We talk about arthritis of the shoulder, we’re talking about arthritis of the main joint of the shoulder so the ball and socket joint. There is a small joint above the shoulder called the AC or acromioclavicular joint. This is the joint between the collarbone and the point of the shoulder. Almost everybody gets so-called arthritis and that joint it wears in everybody, but it often doesn’t cause any pain.
So again on an imaging report, particularly MRI, you may see the word arthritis, but if it’s arthritis of the AC or acromioclavicular joint, it’s probably not the issue.
In some cases that can be inflamed and painful just right on the top of the shoulder. But when we talk about shoulder arthritis we’re talking about the deeper joint – the main ball and socket and arthritis is wearing away of the cartilage in that joint, so that the joint surfaces become irregularly shaped and the joint space is lost, and that causes pain and stiffness.
There are many options for treating shoulder arthritis similar to arthritis and other major joints in the body.
The main goal is pain relief whatever way we achieve it.
Some patients find that just taking some simple painkillers can help them enough that they don’t need to consider anything else. With physiotherapy sometimes it’s helpful, sometimes it can aggravate the Arthritis a little bit so we try it and see, and it’s usually a gentle approach with physiotherapy if it’s not helping then we don’t push it.
Injections can be helpful, they’re not going to change the underlying arthritis itself but they may help with the pain that is secondary to the inflammation caused by the Arthritis so again cortisone injections being anti-inflammatory. We also use other types of injections – what we call viscosupplementation, which basically mimics the joint fluid and theoretically acts to lubricate the joint. It works for some patients but not as often as cortisone works in mild cases of arthritis or younger patients something called PRP or platelet rich plasma can be an option as well.
In some cases, a keyhole surgery or arthroscopy can be appropriate again in the earlier stages of arthritis where we clean out the joint, take away some of the inflamed structures. But again, we’re not altering the underlying arthritis.
The only thing that really takes that away is doing a shoulder replacement, which is an operation quite similar to a hip replacement. It’s the most definitive ways to actually treat shoulder arthritis and get rid of it.
We are a little bit hesitant to do it in younger patients in their 40s or early 50s, because of how long the implants last they last pretty well for 15 or 20 years but it depends what you do with them.
So if there’s heavy use of the shoulders or high impact activities, then you may wear out the shoulder replacement sooner, but a lot of sports and recreation activities are just fine to do with a shoulder replacement.
It’s usually an X ray that we start with when somebody has shoulder arthritis. And then if we are at the point of considering a shoulder replacement we get a CT scan that allows us to see the shape of the bones more precisely in particular the socket of the shoulder, and that allows us to plan each individual surgery using 3d software.
This is a picture of a shoulder replacement. It has a stem, and then a metal ball and a plastic socket. Sometimes we use a slightly different configuration called a reverse shoulder replacement. That’s done in situations where either: there’s a rotator cuff problem in addition to the arthritis or perhaps even a rotator cuff problem on its own where the tendons are gone beyond repair. Or if there’s so much wear of the socket of the shoulder that we can’t fit a regular shoulder socket on there. Then we go to our reverse shoulder replacement,
The rehab and recovery is very similar for both. The surgery is done under a general anaesthetic and most people spend about two nights in the hospital – four weeks in a sling or shoulder immobilizer afterwards again it’s that one with a pillow, and that’s to allow the structures around the shoulder to heal.
In patients who have really bad arthritis pain – they often find that post-surgical pain is almost nothing and that the pain relief is dramatic because their arthritis has gone.
We work on regaining range of motion in the shoulder with physiotherapy after surgery.
In shoulders that have been extremely stiff for a long time we don’t necessarily expect completely normal range of motion, but certainly a much more functional range of motion, than before surgery. The biggest gain that we see early on is the pain relief, it probably takes about six months to get the most out of your shoulder replacements after surgery.
Future of shoulder surgery
The future is already here in terms of shoulder surgery and shoulder replacements. This is the CT planning program that I use on every patient who has a shoulder replacement with me. It allows us to see your shoulder in much more detail and plan things very precisely for your individual operation.
We can even order a 3d printed guide, based on your specific anatomy of the socket of your shoulder and that is something we then take into the operating theatre with us, and it directs a key part of the surgery in terms of placing the component on the socket of your shoulder.
The next step is augmented reality where we are able to project your CT scan on a hologram in front of the surgeon during the surgery and again that allows us to be even more accurate in how we’re putting in the shoulder replacement, which we hope will translate in the future into the shoulder replacements lasted even longer.
So while shoulder replacement is not as well-known as hip and knee replacement it’s something that’s been around for the last couple of decades and it’s something that’s evolving a lot – we have a great amount of success with it and it’s something that if it’s appropriate for your shoulder to shoulder specialist will be able to discuss it with you.
So I hope that’s been helpful. It’s a quick tour of some of the really more common shoulder problems that we see and I’ll be happy and I will be happy to answer any questions you have afterwards.
|For further information on this topic or to make an appointment with an Orthopaedic Surgeon please email email@example.com|
Fiona Roche (FR) Business Development Manager at SSC put some of the audience’s questions to Ruth Delaney (RD).
FR: Ruth thanks for a really interesting talk – we have a lot of questions coming through for you this evening. The first one is from Michelle: She has had a recent MRI diagnosed full-thickness tear, use of the supraspinous ligament. Is surgery the only option for her, and if so how long after surgery would she expect the full movement of her shoulder?
|RD: Well, I suppose before we dive into any of the questions, I will just say that anything that I say here obviously isn’t specific medical advice for any individual patient without knowing the full story and examining someone – I am just giving general thoughts on the questions that are raised.|
So in terms of that question, we probably touched a little bit on it with the talks where surgery is not necessarily the only option.
It depends on the size of the tear, age and activity level of the patient. Some Rotator Cuff Tears can be managed without surgery – physiotherapy can compensate with the other muscles of the rotator cuff that are left. Sometimes an injection forms part of a pain relief strategy.
Sometimes we will advise surgery for a bigger tear. In terms of post-op rehab, it is slow – I suppose full use and full activities would be 6 months, but it is graded, so by 3 months you would be doing most day to day things, no heavy lifting, and by 6 months you will be back to all of your activities after a rotator cuff repair surgery.
FR: Question from Sue: she has also torn her supraspinatus and calcification of the biceps which ruptured a full 8 months ago. She says is it too late for surgery as she continues to have discomfort and occasional pain in her upper arm, with limited movement but full function?
RD: Again it kind of depends on the tendon tear – sometimes it can be too late for surgery if it is a very large tear and the muscle has started to waste away – too late for repair surgery, but there are other types of surgery that can be done. So it would depend on exactly the size of the tear. I suppose there are often other things we can do, be it grafting the rotator cuff or just cleaning out the shoulder to take care of pain if the shoulder is still functional or in very severe cases even replacement type operations. So it is never too late for us to be able to do something – it is always worth looking at if the shoulder isn’t something you can live with.
FR: Sylvia had an MRI on her shoulder which shows nothing. Would you recommend having an ultrasound? It is very painful, feels like bones are rubbing and very hard to raise her arm.
RD: Yeah I think the MRI isn’t the be-all and end-all, you can have something causing pain in your shoulder that isn’t obvious on an MRI, and might be more obvious to us when we examine your shoulder. If the MRI hasn’t shown up much, it is very unlikely that an ultrasound will show anything different because an MRI is more detailed than an ultrasound. I would say probably having somebody who specialises in shoulders actually examine your shoulder would probably give you more information than further imaging tests or ultrasounds on that situation.
FR: I am asking a question here from Liam: he says he has an implanted defibrillator – can he get an MRI or other insights for shoulder pain?
RD: Good question. It is a pretty common scenario. Sometimes you might not actually even need an MRI. If you do really need an MRI, there are ways to get it, but it depends on the exact defibrillator device you have and on the facility where you are going to have the MRI and it is often the case that they have to do something special to turn off the defibrillator because the MRI is a big magnet.
But if you take a step back and just make sure that you actually really need an MRI, because a lot of shoulders that get sent to MRI didn’t really need them – sometimes X-Ray and a good clinical exam will give all the information we need, other times we can find a way around it if we are looking at the soft tissues an MRI would evaluate – we can look at them with ultrasound, it is not as detailed but we can see them. The other option that we sometimes use is CT scan, this goes for people who are claustrophobic too and would have a really hard time tolerating an MRI.
Maybe let a shoulder specialist look at your shoulder first and determine whether you really need the MRI.
FR: Getting a COVID injection in an already painful shoulder, is that ok?
RD: It is unlikely to make the shoulder problem worse. There are rare situations with any vaccine where we see something called ‘shoulder related injury related to vaccine administration, and it can happen that it flares up a shoulder.
I suppose the most sensible thing to do is to just get it on the other shoulder unless there is a good reason not to have it on the other shoulder.
The injection for the vaccine should just go in the deltoid muscle and in a body of the muscle rather than into any of the structures deep into the shoulder but I think you are going to be sore for a day or two after your Covid injection – I would probably put it in the other shoulder and know it is going to get better in a day or two.
FR: Tom is a 60-year-old male living with rheumatoid arthritis. After doing some painting, or working with the shovel while gardening etc. he developed severe shoulder pain within two days to the point where it is impossible to lift his hand up to his face and after 6 days though on steroids it seems to be sorted?
RD: Well the fact that it responds very quickly to steroids would suggest an inflammatory cause of his pain. With rheumatoid arthritis, that could be the rheumatoid arthritis affecting the shoulder or it could also be something else in the shoulder causing inflammation like a rotator cuff problem.
Obviously going on oral steroids over and over again isn’t a long term solution so I think just getting an assessment of the shoulder, starting off with an X-Ray, seeing if it is arthritic, getting an examination, seeing if the rotator cuff is weak – sometimes we can inject the steroid around the shoulder and it will calm it down, but if it is a reoccurring problem then we might need to look at doing something more definitive. So I think just starting with an assessment of the shoulder overall in the context of the background of the rheumatoid and see where it’s at.
FR: There is a question here from Cliona: experience of adhesions under the shoulder blade in the region of the mid-thoracic area on the back where the blade sits on the rib cage on the back.
RD: We see that from time to time, what we call ‘scapula thoracic bursitis’ – obviously scapula/shoulder blade and thoracic/rib cage. The shoulder blade is really important in how the shoulder works – it sits on the back and the ribs are underneath the shoulder blade. The shoulder blade has to move around like this to allow the shoulder to actually move. There is a layer of connected tissue/fluid line that helps the shoulder blade to slide around – that can get inflamed sometimes. Sometimes we do an injection underneath there, very occasionally we do surgery underneath there. It is less common than injecting other areas around the shoulder and usually, physiotherapy would have a major role in that help with the control of the shoulder blade. It is a tricky area to inject because the lungs are not too far away – so it is something we weigh up with the patient, but it is something we can treat quite successfully.
|To make an appointment with Ms Ruth Delaney please contact firstname.lastname@example.org or call 01 5262335.|
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