Common Shoulder Problems with Mr Hannan Mullett

I am Hannan Mullett, I’m one of the shoulder surgeons here at the UPMC Sports Surgery Clinic and I’d like to talk to you today about some of the common shoulder problems.

Shoulder problems are very common and it ranks second only to back pain is the most common reason why people might lose work due to musculoskeletal problems, it can be due to someone’s occupation because they are involved in heavy lifting or more commonly nowadays, is that static posture or working at desks or in a fixed position for a long time.

When you look at your shoulder problem on the Internet, you get bamboozled with all this information about different types of tests and different types of treatment, some of them are reliable types of treatments and some of them are not.

So I’m going to talk a little bit about the most common type of problems we see. For the non-injury type of shoulder problems, wear and tear type problems, the most common problems I see are problems with the rotator cuff. And this can go from somebody where the tendon is intact but rubbing against the overlying bone to people who have torn the rotator cuff. Another common problem is a frozen shoulder, which is common particularly in middle-aged women. Arthritis, probably not as common in the shoulder as is in the hip and knee, but it is a common cause of shoulder pain. I’m not going to really talk today much about sports injuries. It’s more about the wear and tear type of problems we see in the general population.

There are two main parts to the shoulder, the scapula or the shoulder blade and then the humorous, which is the arm bone and at the top of your shoulder you have the collarbones.

The collarbone acts as a type of strut to hold the shoulder blade in position and then allow the ball and socket joint to move so that you can place your arm overhead.

If we go to the next layer, if you like, in terms of the anatomy, we can see that the various muscles around the shoulder and the ones that cause us the most concern, really, are the rotator cuff muscles, which are a group of tendons around the ball and socket joint, the power of the shoulder and particularly the one at the top, the supraspinatus can impinge against the bone and cause pain.

In terms of the rotator cuff, the one that’s most commonly injured is the one at the top called the supraspinatus, which brings the arm out from the side and then the less commonly the infraspinatus, which brings the arm out from the body. These are commonly a source of inflammation and also, they can tear and need attention.

In terms of the rotator cuff, it can go all the way from tendinitis or inflammation of the tendon all the way to a rotator cuff tear and then some patients who have rotator cuff tear, can then develop arthritis due to that tear. About 10 per cent of people with a major rotator cuff tear can get arthritis due to that tear.

As to why some people just get tendonitis and some people it develops into a full tear, this can due to their age and more likely as you get older or if they’ve had an episode of trauma or maybe their occupation. But there is a strong genetic element as in a lot of things in life you can blame your parents!

When we look at the type of treatments, it really depends on how bad the condition is, we can start off with things like physiotherapy or injections are often very helpful, particularly if we want to avoid surgery in the earlier stages of treatment.

Some rotator cuff problems are amenable to keyhole surgery. This can involve either taking away spurs of bone or in fact repairing the tendon.

Some types of rotator cuff tears require open surgery, though this is becoming less common nowadays and then the ultimately small number of the overall patients who develop rotator cuff problems require shoulder replacement surgery.

One of the most common shoulder conditions is impingement. In this image, you can see this long bay structure is the humorous of the arm bone then they have the tendons or the rotator cuff. There is a fluid-filled sac called the bursa and as the patient raises their arm, they can get impingement or pressure on the rotator cuff on the Bursa as it rubs against the bone spur above it.

And in fact, you can get this vicious cycle so that a patient gets a little bit of inflammation in the tendon, the tendon then becomes thicker and inflamed and then more likely to impinge and cause pain.

This is what’s happening in this animation as the patient raises their arms. You can see the tendon impinges against the bone and the ligaments and this is what we see if we end up putting a camera into the shoulder. This is rotator cuff tendonitis. In fact, there’s a lot of terminologies that crosses over so if you get an MRI report showing rotator cuff tendinitis, that’s the same as impingement, which is generally the same as a partial thickness tear.

When you examine the patient, they as they raise their arm up in the air, they may be comfortable when they have their arm down one side and then when they raise their arm up in the air pinches and they get a positive impingement.

When patients have a lot of shoulder pain and are sent by their General Practitioner or by the physio for an MRI scan they are often a little bit disappointed when the result comes back and shows in fact the rotator cuff is intact. Because when the MRI scan is done, you’re lying in this tube in the hospital with your arms down by your side, which is the most undemanding position for the rotator cuffs and it’s not very sensitive for looking at rotator cuff tendinitis.

It is useful in that it can distinguish from other shoulder problems like a full-thickness tear, rotator cuff or arthritis of the ball and socket joint but it doesn’t make the diagnosis you have to examine the patient and take the history of the story that they’re telling into the context as well as to what you’re going to do.

So in terms of treatment, when somebody has a rotator cuff tendinitis, you tend to avoid aggravating factors, if you are a plasterer and you do a lot of overhead activity to try and minimize this there are some occupations particularly plasterers or hairdressers or people where you’re using your arm in a position that aggregates your rotator cuff.

It is reasonable to start off with anti-inflammatory medication for a few weeks. Physiotherapy is also very useful and I certainly would try physiotherapy, anti-inflammatories and simple things before moving on some more complicated things.

If patients have had it generally for more than six weeks or sometimes if it’s very severe, one would think about a steroid injection but we don’t really like to inject the body unless you’ve tried everything else.

Generally, I avoid steroid injections and they’re very useful, but I try not to do it on patients unless they have had it for more than six week period.

Exercises are useful, simple stretches such as standing and raising your shoulders, holding for five, seven seconds and then back down again, squeezing your shoulder blades together and holding five seconds, or putting your shoulder blades down and holding for five seconds is useful. These type of stretches, particularly if you have some stiffness when you’re lacking a little range of motion when you test it out doing simple exercises like this or stretches with your arm across your chest or event this one which you can do against a door frame – these are all useful rotator cuff stretching exercises, which you should do before seeking any medical attention.

So if you had you’ve tried the injection or you’ve tried the anti-inflammatories, you’ve tried the physiotherapy, it’s you’re still in trouble, you are getting night pain and pain at night then it is reasonable to try a steroid injection. This can be done fairly readily. It can either done by the radiologist or in fact, it’s a fairly large target that you’re injecting into this large bursa, so it’s very convenient for the patients to be injected in my office, which saves them coming back another time.

This is said generally takes a couple of minutes to do. It is safe. There’s about a one in 10 chance that it’s a bit more painful for a day or two and about one in a thousand people, unfortunately, can get an infection from any injection. This is more common perhaps that they’re diabetics or other risk factors.

So in patients, the small number of patients require surgery. Here we are looking at the right shoulder from behind, the metallic instrument here is a shaver and I am using that to take away the thickened bursa and also in this part of the operation to take away spurs of bone that are impinging against the tendon.

This can be performed as a day case surgery, it’s done through three very small 3mm incisions. The patient wears a sling for a number of days and generally, they can get back to normal activities, such as driving within that four or five days.

Patients also have a small joint to the top of the shoulder between the collarbone and the other edge of the shoulder. This is not an important joint, but in everybody, 100 per cent of people, it gets worn as we age. So if you’re over 40, you get an MRI scan of your shoulder it’s definitely going to show the general change of the AC joint (acromioclavicular joint).

In most patients, this is not a source of pain, but it can be.  If you have pain when you cross your chest and at the very extremes of movement, this is more in keeping with it AC joint type pain and this can also be injected and ultimately if it is giving enough trouble this can also be addressed through keyhole surgery.

If you’re over 40 and you get your MRI scan results, it will always show degenerative changes of the AC joint and you may be told by somebody that you have arthritis in your shoulder. Well, the arthritis is in a very small part of the shoulder and it may be that the rest of the shoulder, in fact, is completely normal.

So what about when we move on then, we’ve spoken about it a little bit about the impingement and rotator cuff tendonitis and we’ve spoken about the general change of the AC joint. What about tears?

There is an old adage that grey hair equals old tear, and certainly, as you get older, there’s a greater likelihood that you’re going to have a rotator cuff tear.

By the time you reach 80 years of age, 80% of people will have a rotator cuff tear, which doesn’t mean that we need to do anything with it unless it’s causing some symptoms. And generally, it’s important you can separate rotator cuff tears as to whether they’re an acute tear, i.e. due to, you lift something heavy or you fall or you trip over the dog and you have your normal shoulder and then you tear the rotator cuff as opposed to the kind of wear and tear type of rotator cuff problem, a degenerative rotator cuff tear.

Generally, if somebody is fit and healthy and otherwise in good shape, if they tear the rotator cuff due to an injury, we tend to repair it. If they have a wear and tear type of rotator cuff problem, we try to treat it with tried physiotherapy and perhaps one or two injections. Rotator cuff tear are generally rare under the age of 40 but as we age, they become more prevalent and most patients over 70 will have some degenerative changes in their rotator cuff.

When you put a camera in the shoulder this is what it looks like, this is the edge of the bone here with a tendon should be attached and the rotator cuff has kind of pulled off the bone with a significant tear. This is a patient here so he raises the left arm without any difficulty and is having great difficulty raising his right arm and when he tries to bring his arm out from his side, even when we try and help him to bring it from his side it just flops back. This is a sign of a pretty severe rotator cuff tear.

As to whether you repair it or not, we generally say with a wear and tear type of tear, we try and treat it with physiotherapy injections, first of all. But if somebody has a fall or an injury, we tend to try and repair it. And in fact, if you have a traumatic tear, i.e., due to an injury, you’re better off having it fixed sooner rather than later because the tissue tends to lose its elasticity and becomes more difficult to repair.

In most patients who come for intervention for their rotator cuff tears, the most common symptom is that they get pain at night. So they have difficulty lying on this side and it disturbs their sleep. To a lesser extent, they come with a weakness, for example, difficulty carrying a pot of tea or something with our arm outstretched or less commonly that the shoulder is unstable or pumping in and out, which is what happens really only with more extreme levels of rotator cuff tear.

It is important that the doctor or the physiotherapist usually starts by taking a history and an examination and then move on to the MRI scan rather than working from the MRI back because as I said if you’re 70 plus your MRI, is unlikely it’s going to show an intact rotator cuff. So we don’t treat the MRI we treat the patient initially.

And this is what it looks like, this is when I put a camera into somebody’s shoulder. This is a right shoulder and we are looking at it from behind. I am using an instrument to assess the white structure here is the rotator cuff. This was somebody who had fallen and I am just checking to see if we can repair the rotator cuff which thankfully we were able to do on this occasion.

Traditionally this was done openly and still, some people do it through an open technique. There’s nothing wrong with that except that it tends to be a little bit more painful that you need a more prolonged inpatient stay and the mobilisation is longer and you tend to get scarring between the various layers between the outer muscle and the rotator cuff and approximately 20 per cent of people with an open repair, will develop stiffness.

As part of the repair, we take away the outer surface of the bone and clear out any scar tissue and then use special instruments to pass stitches or sutures through the rotator cuff, and then we tie these together, then put them into what we call an anchor, which attaches the rotator cuff to the bone.

So the technology has certainly advanced even over the last five to 10 years, making this a lot easier to do and keyhole surgery, if it works well,  saves the patient a lot in terms of open surgery and here I have passed the sutures through the tendon and am now putting the anchor into the bone so that hopefully the patient will heal the tendon to the bone.

Next, I will talk about a very common problem called frozen shoulder. Generally, it happens between the age of 40 and 60. It is a bit more common in women than in men. People with diabetes and thyroid problems can get a more severe form.

There is generally no particular cause for it but it can happen after a minor injury. So somebody trips over the dog or trips over the curb, and within a few weeks their shoulder becomes painful and they put it down to the injury but it may just be the thing that triggered the frozen shoulder and in fact, you can develop a frozen shoulder after surgery.

This could be shoulder surgery, for example, if you have your bone spurs removed in the first operation, I described a small percentage people can that can trigger a frozen shoulder or it can be triggered by it used to be quite common with open-heart surgery or a breast surgery in women. That can be cause for it. So what happens is there’s a thin membrane or a lining of the joint between the ball and socket joint and this becomes red and angry and thickened.

Patients present really with severe shoulder pain with a frozen shoulder, particularly if they overstretch. The Americans call it ‘jerk pain.’ So if they reach for somebody, they get searing pain. They also have significant night pain and sleep disturbance and then the shoulder becomes restricted and they notice restricted range motion, for example, tying their bra.

Luckily only get it once per side but if you get it on one side, you’ve at least 10 per cent chance of getting the other side. Generally, it takes nine to twelve months to resolve but it can be as long as two years.

There are three stages. The first stage is the most painful stage, usually will last four to six months. The shoulder is painful with restricted movement, pain at night, pain if you’re overstretched. The second stage, the pain gets better, but it still remains restricted and the third stage, it comes back to normal.

In the first stage, I often send patients for physiotherapy. Although physiotherapy for shoulders is generally a very good thing for stage one frozen shoulder, it tends to be too painful and it can actually just aggravate things to some extent. The Physio can help by mobilizing the neck and the shoulder blade but the ball and socket joint is too painful so in the first stage, taking painkillers can be helpful and I find, in fact, injecting the shoulder when somebody has a stage one frozen shoulder really helps the pain.

The second stage physiotherapy is more useful and the second and third stage, generally, the patient is much more comfortable and if they are happy in the knowledge that it’s going to get better over time, a lot of them do not need any further treatment. Probably about maybe 10 per cent of patients where it doesn’t improve within a satisfactory timeframe then we end up doing keyhole surgery.

This is what I do in keyhole surgery. This is the right shoulder. We’re looking from behind the white structure to the right side of the field is the ball and I’m taking away all this very abnormal red, angry, inflamed and thickened tissue, which is the thickened capsule. which is the structure causing the frozen shoulder. This generally can be performed as day-case surgery as its relatively straightforward. The patient just uses a sling for a number of days and does a lot of physio after this to try and keep the movement.

Next, we move on to shoulder arthritis. You have probably had, or maybe your friends have had joints replaced such as hip or knee replacement. Shoulder replacement is not as common an operation, but it is the third most commonly performed surgery.

Shoulder arthritis tends to occur at a slightly older age group, and as we survive longer, more and more shoulder replacements are being performed. In fact, the technology for shoulder replacement surgery has increased fairly dramatically over the last couple of years, so it’s a lot more successful.

This x-ray shows the normal ball and socket joint is very narrowed and there are lots of new bone formations called osteophytes, which is the cause of the problems. If the patient is suitable for it, we can do a lesser procedure where we don’t put long stems down the centre of the bone, we call it a stemless procedure. In fact its the operation I generally perform for this so we would cut the arthritic part of the bone away and then we take away a core of bone and then measure the distance between the cut surface and the outer edge of the bone and then we can put in the components.

The components are made and to accommodate for different sizes so that there’s an array of different supports plates called the trunnion. Then we advance this with what we call it a cage screw. It is a hollow screw that goes into the top part of the arm bone. Here we see the impaction of the metallic humeral head and this allows the preservation of the bone in case they need further surgery. The humeral head articulates with a plastic socket that is cemented into the shoulder blade.

The other type of shoulder arthritis we see which is probably on the increase as people live longer and lead healthier lives is arthritis due to a significant rotator cuff tear. This generally occurs in people over 75 years of age.  This usually presents with an arm that’s painful, but the patient can’t really do their normal activities – even putting a key in the door can be trouble so they can lose their independence.

This is a different type of shoulder replacement where it’s called a reverse geometry shoulder replacement. So in this, you can see on the left side of the image there, we have the normal ball and socket joint and we replace this by putting a ball in the socket, under the socket and the arm bone, so we reverse the geometry of the shoulder replacement and this is done to allow us to take advantage of the fact that the outermost of the deltoid is intact so we restore what is called the fulcrum of the shoulder.

This is what it looks like on an x-ray. It’s a slightly more invasive surgery than the other type of shoulder replacement but, in fact, patients recover generally very reliably afterwards.  They wear a sling for four weeks, and often when they come back for their post-op visit, at four to six weeks, they have better movement, particularly in terms of raising their arms above the horizontal than they did before the operation.

In fact, after they reverse geometry, shoulder replacement, the patients can, in fact, regain a range of motion and have a fairly comfortable shoulder in a very quick time frame.