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PATIENT SHOULDER RELATED QUESTIONS

Join Dr Raymond Yu in answering your questions. Post a comment on the Facebook Post specific for SHOULDERS and Dr Yu will read, and answer most questions on here. The current segment is focussing on Shoulder Pain, Shoulder Arthritis and Sports injuries of the Shoulder. Please note that sensitive medical information will not be disclosed on this page. This area will be used for general questions that can be used to help others that may have the same questions as you.

How To Ask a Question
Just click the link above, and you will be brought to the relevant Facebook post. This will be related to the appropriate body part. Ask you question, and you will receive a notification on our Facebook page that your answer has been added to the Ask the Surgeon answers below.
e.g. What is a shoulder replacement

A total shoulder replacement is an operation used to reduce the pain that you would experience from shoulder arthritis.

What is the best way to treat bursitis?

What is the best way to treat bursitis?

Good question, and one that is often asked as this is a common shoulder problem. Shoulder ‘bursitis’ is a condition synonymous with shoulder ‘impingement’ and ‘painful arc’. 

A bursa is a normal fluid filled sac, which helps cushion soft tissue structures from bony prominences. Within the shoulder, there are multiple bursas, but the one that can become problematic is called the ‘subacromial bursa’. This sits just above the ball of the shoulder joint, and normally cushions the rotator cuff tendons from a shelf of bone which protrudes from the shoulder blade. 

For a number of reasons, including repetitive use, the bursa can become inflamed. When this occurs, it thickens and becomes adherent to the underlying rotator cuff tendon. When bringing your arm overhead, the bursa can catch between the ball of the humerus and the shoulder blade, causing a classic ‘painful arc’. This condition is also called ‘impingement’. 

There are several treatment options for symptomatic bursitis. The first line of treatment is non-operative management. This consists of a combination of:

  • Rest – resting the affected shoulder from the overhead movements or activities which exacerbate the pain can help settle an inflamed bursa. This may also involve adjusting the way or technique you do things.
  • Anti-inflammatories – non-steroidal anti-inflammatory tablets can be trialled in the short term. They can cause gastric upset and bleeding, so should not be used regularly for more than 2-3 weeks.
  • Physiotherapy – physiotherapy is beneficial to maintain flexibility and range of motion in the shoulder, as well as to strengthen the muscles around the joint.
  • Injections – occasional steroid injections (no more than 2 or 3 per year) can be trialled to relieve the symptoms or to help pinpoint the location of pain.

If the above options have been trialled and are unsuccessful, then surgery may be of benefit. The type of surgery involved is a keyhole operation known as ‘arthroscopy’. Through tiny incisions in the skin, the inflamed bursa is removed, as well as bony spurs which contribute to shoulder impingement. This procedure is often performed as day surgery, with a sling used for comfort for a few days. The aim is to commence range of motion exercises of the shoulder immediately in the post-operative period. 

I hope this helps answer your question. You can read more about shoulder bursitis and its treatment here: https://drraymondyu.com.au/shoulder/conditions/subacromial-impingement/

 

 

 

How do you treat pain the shoulder blade?

How do you treat pain the shoulder blade?

This is a good question, but in order to receive the best treatment to target the cause of the pain, an accurate diagnosis must first be made.

The shoulder as we think of it is actually made up of several joints. The way the shoulder blade lies on the back of the chest wall is technically a joint also – the ‘scapulothoracic’ joint. When you lift your arm above your head, 2/3 of the motion comes from the ball and socket part of the shoulder, but 1/3 comes from this scapulothoracic joint. As well as this, there are 17 different muscles which are attached to the shoulder blade!

When there is a problem with one or more of the muscles attached to the shoulder blade, this can affect the way the shoulder blade moves on the back of the chest wall. This can then be felt as shoulder blade pain or discomfort, and is sometimes called ‘dyskinesia’ of the shoulder blade.

Another potential cause of shoulder blade pain occurs when nerves around the shoulder become pinched or compressed. The nerves around the shoulder are collectively called the ‘brachial plexus’, and several nerves which branch from it supply muscles around the shoulder blade. A problem involving these nerves needs to be thoroughly investigated.

As a general rule, simple treatments can be trialled first for shoulder blade pain. This includes resting the affected arm from aggravating movements or activities, simple analgesia such as panadol or ibuprofen, and physiotherapy to strengthen the muscles around the scapula.

If these are unsuccessful, then further investigation to pinpoint the cause of the pain is required. Often this necessitates a clinical assessment by your GP or an orthopaedic surgeon. Further tests may be required, including scans and selective injections. Occasionally the solution involves a targeted surgical procedure.

I understand this is a broad answer, but I hope it helps answer your question.

 

Shoulder pain not responding to cortisone injection

I have bursitis in my left shoulder I’ve had a cortisone and waiting for another but it’s been four months and I’m still in pain. Should I get a second opinion.

Hello, and thanks for your question. I am very sorry to hear that you have ongoing shoulder pain after a cortisone injection.

One thing to understand about these injections is that they have a two-pronged purpose. The first purpose is to try and relieve your shoulder pain completely, and for good! Unfortunately, sometimes the steroid injection may only take away your pain temporarily. Even if it does not relieve the pain permanently, this still serves the second purpose of identifying the likely source or cause of your shoulder pain, depending on where the injection was placed.

For example, if the injection was made into the bursa of the shoulder, and this relieved your pain briefly but then the pain returned, this likely confirms that the bursa is the main cause of your symptoms. If the bursal pain persists despite non-operative treatments (ie. rest, simple analgesia, physiotherapy) then you may be a candidate for targeted surgical treatment. For further information about bursitis and its treatment, please see https://drraymondyu.com.au/shoulder/conditions/subacromial-impingement/

If however, your injection into the bursa did NOT relieve your pain even temporarily, then further clinical assessment is required to make a clear and accurate diagnosis. This involves seeing your GP or orthopaedic surgeon for a thorough review and examination. Further tests may be required also, such as scans or injections targeting other locations within the shoulder (eg. the AC joint, the glenohumeral joint, the biceps tendon). Once a precise diagnosis has been made, then the appropriate treatment for it can be initiated.

I wish you the best of luck, and hope this helps answer your question.

What is the recommended Cortisone injection frequency?

How many cortisone injections is recommended for the shoulder and if its 12 months apart does that make a difference? 

This is an often asked question, as targeted injections make up part of the first-line treatment for shoulder pain.

Cortisone is an anti-inflammatory steroid and is injected with local anaesthetic into a pre-determined area of the shoulder, and usually performed under ultrasound guidance. The most common location in the shoulder that is injected with cortisone is in the ‘subacromial’ space. This is the part of the shoulder above the ball of the arm bone where there is a bursa that can become inflamed and thickened, and can cause impingement pain. The aim of the cortisone is to reduce the acute pain and inflammation associated with bursitis.

However, too much cortisone can also potentially degrade the quality of the rotator cuff tendons and thin the tendon tissue. If the rotator cuff tendon is torn, then cortisone can actually delay or prevent the tear from healing.

Nevertheless, a single selective injection of cortisone with anaesthetic can be useful to both relieve acute shoulder pain, as well as aid in pinpointing the precise location of the pain. Occasionally, if an injection has failed to provide pain relief even temporarily, then further diagnostic injections to other regions within the shoulder may be warranted. These other areas include the AC joint, the Glenohumeral joint, and the biceps groove. However, as a general rule, I would not recommend having more than 2 or 3 cortisone injections per year.

I hope this helps to answer your question. You can read more about my approach to shoulder pain here: 

https://drraymondyu.com.au/shoulder/conditions/shoulder-pain/ 

 

 

Shoulder and shoulder blade pain with no clear diagnosis

“Severe pain in left shoulder/shoulder blade daily, this can flare up worse on occasions and cause pain to radiate to chest, this happens often…have been to hospital and not the heart, unsure what the pain in the blade area is hasn’t been explained to me”

Hello and thank you for posting about your problem. I am sorry to hear that you have been living with this shoulder pain without a clear diagnosis.

Similar to an earlier question regarding pain in the shoulder blade, the best treatment for it cannot be fully initiated until a precise diagnosis has been made.

There are many potential causes for pain that is felt around the shoulder and shoulder blade. Sometimes the heart or lungs can cause sharp pain felt at the very tip of the shoulder blade. Occasionally problems with neck and cervical spine may cause pain to the shoulder and arm. If these have been excluded then attention should be given to the muscles and joints around the shoulder.

The shoulder blade lies on the back of the chest wall and actually rotates on the chest wall when the arm moves. It is responsible for 1/3 of the movement of the arm, and is supported by 17 different muscles surrounding the shoulder blade.

If your pain is worse when moving the arm above your head, then there is a good chance it is due to an issue with the muscles or joints of the shoulder. Problems with shoulder blade rotation and movement is called “dyskinesia”.

First line treatments include rest and avoidance of aggravating activities; paracetamol and non-steroidal anti-inflammatories (such as ibuprofen); and physiotherapy.

If these simple treatments are unsuccessful, then further assessment by your GP or via referral to an Orthopaedic Shoulder Surgeon may be warranted. Scans that may be helpful include xrays, ultrasound and MRI (Magnetic Resonance Imaging), and these can be arranged by your doctor.

If you’d like to learn more about the common conditions and treatments for shoulder pain, please read my article at: https://drraymondyu.com.au/shoulder/conditions/shoulder-pain/

Do labral tears, subacromial bursitis, or supraspinatus tendinosus mean surgery?

Does focal anterosuperior labral tear chronic and small posterosuperior labral tear plus subacromial bursitis and supraspinatus tendinosus likely mean surgery?

Thank you for your question. This is obviously very specific to your situation and your shoulder, but I’ll try to answer in a more broad sense. 

Firstly, it’s worthwhile having some understanding of the various anatomic terms used in the shoulder. The ‘labrum’ is a ring of fibrocartilage which encircles the shoulder socket. It helps to deepen the socket and is the attachment point for the ligaments around the shoulder, as well as where the biceps tendon originates. Tears of the labrum can be ‘acute’, meaning happening suddenly, and this is often associated with a traumatic injury. Tears of the labrum may also be ‘chronic’, meaning it has been present for a while, and often due to long term ‘wear and tear’. If the labral tear is not associated with any pain, then it does not require surgical treatment. On the other hand, if the labral tear is causing pain or is associated with shoulder dislocations and instability, then it certainly warrants further investigation by a Shoulder Surgeon. Read more about labral tears here https://drraymondyu.com.au/shoulder/conditions/instability/ 

‘Subacromial bursitis’ is an inflammation of the bursa (a fluid filled sac) which sits above the rotator cuff tendons in the shoulder. When inflamed and thickened, it can catch and cause impingement pain, particularly with overhead movements. Simple treatment regimes include rest, anti-inflammatory tablets, and selective steroid injections. If these measures fail to improve the pain, then a keyhole decompression operation can be considered.  Read more about bursitis here https://drraymondyu.com.au/shoulder/conditions/subacromial-impingement/ 

Finally, ‘supraspinatus tendinosus’ refers to an unhealthy rotator cuff tendon. The supraspinatus tendon is responsible for elevating the arm above your head. ‘Tendinosus’ is a term used to describe a tendon which is disorganised and thinned out. Tendinosus itself does not require surgery, and the pain associated with it usually responds to simple analgesia and rest. However, an unhealthy tendon with ‘tendinosus’ is at a higher risk of sustaining a rotator cuff tear. This can lead to weakness and loss of function, and should be further investigated by your doctor to determine if it is able to be repaired surgically. 

Depending on your own constellation of symptoms (eg. pain, weakness, stiffness, loss of function) and the precise cause of the shoulder symptoms, further clinical assessment and investigation may be required. A combination of non-operative and operative options may be available for the specific cause of your problem. I hope this has helped answer your question.

 

 

Is a shoulder replacement the only option for bone on bone?

Is a shoulder replacement the only option for bone on bone?

This is a great question and one that I get asked by my patients very often. The answer I give is unique to each individual patient, and takes into account several factors. 

For those unsure, ‘bone on bone’ is a term used to describe arthritis. Arthritis is a condition where the smooth joint cartilage becomes damaged. Unfortunately this special cartilage does not grow back, and over time the underlying hard bone becomes exposed. This can progress until eventually, bone is rubbing against bone within the joint, causing stiffness and pain. 

The shoulder is the most mobile joint in the body, so when arthritis affects the shoulder, it can be incredibly debilitating. Non-operative treatment options include avoiding / modifying the activities that aggravate your shoulder, paracetamol, anti-inflammatories, physiotherapy and selective cortisone injections. 

If however, the pain continues to stop you from doing simple everyday tasks such as getting dressed, washing your hair, or hanging the washing, then further opinion from a Shoulder Surgeon should be sought. One question I ask my patients which can be very revealing is “Does the pain stop you from sleeping, or wake you up at night?” If the answer is ‘yes’ then I understand that the impact on my patients’ quality of life is dramatic. This is when surgery in the form of a shoulder replacement needs to be considered. 

Other less common surgical treatments for arthritis include keyhole surgery to debride the arthritic joint (possible for early/moderate arthritis), and a shoulder fusion (very rare circumstances only). 

A shoulder replacement involves removing the diseased portion of bone, and replacing it with an implant. The goal is to relieve pain, restore movement, and improve function. Various types of shoulder replacements exist, and your Shoulder Surgeon will decide which one is appropriate for you based on the quality of your tendons and bone. Find out more about shoulder replacements here: https://drraymondyu.com.au/shoulder/surgery/shoulder-replacement/ 

I hope you have found this answer helpful.

 

 

Pain underneath the shoulder blade

Been having pain in my left shoulder underneath the blade.

Similar to an earlier question regarding pain in the shoulder blade, the best treatment for it cannot be fully initiated until a precise diagnosis has been made.

There are many potential causes for pain that is felt around the shoulder and shoulder blade. Sometimes the heart or lungs can cause sharp pain felt at the very tip of the shoulder blade. Occasionally problems with neck and cervical spine may cause pain to the shoulder and arm. If these have been excluded then attention should be given to the muscles and joints around the shoulder.

The shoulder blade lies on the back of the chest wall and actually rotates on the chest wall when the arm moves. It is responsible for 1/3 of the movement of the arm, and is supported by 17 different muscles surrounding the shoulder blade.

If your pain is worse when moving the arm above your head, then there is a good chance it is due to an issue with the muscles or joints of the shoulder. Problems with shoulder blade rotation and movement is called “dyskinesia”.

First line treatments include rest and avoidance of aggravating activities; paracetamol and non-steroidal anti-inflammatories (such as ibuprofen); and physiotherapy.

If these simple treatments are unsuccessful, then further assessment by your GP or via referral to an Orthopaedic Shoulder Surgeon may be warranted. Scans that may be helpful include xrays, ultrasound and MRI (Magnetic Resonance Imaging), and these can be arranged by your doctor.

If you’d like to learn more about the common conditions and treatments for shoulder pain, please read my article at: https://drraymondyu.com.au/shoulder/conditions/shoulder-pain/

Weakness after a shoulder replacement

Had a Reverse left shoulder replacement five years ago. During recovery the nurses wanted me higher up the bed but because of the nerve block a nurse helped by lifting my left arm up by the elbow and armpit. In so doing the Deltoid muscle was ruptured and now I have very limited use of the left arm. Is there a possibility of some surgery to help restore use back to normal?

I am very sorry to hear that your shoulder replacement is not functioning as planned. My advice to you would be to ensure that you have been followed up by your original surgeon for a thorough post operative assessment and management specific to your situation.

A shoulder replacement is a great option for ‘bone-on-bone’ arthritis, where the joint cartilage of the shoulder has been worn away completely. This leads severity of arthritis is responsible for pain with every day tasks as well as pain at night. Read my article on shoulder arthritis here https://drraymondyu.com.au/shoulder/conditions/arthritis-2/ 

In the setting of arthritis, the ‘reverse’ design shoulder replacement alters the biomechanics of the shoulder so that less reliance is placed on the rotator cuff muscles. This is because often the rotator cuff muscles are already torn or have a high likelihood of tearing in the near future. In order to achieve elevation of the arm, the ‘reverse’ shoulder replacement relies on the big deltoid muscle of the shoulder. Therefore, a prerequisite for a well functioning reverse shoulder replacement is a well functioning deltoid muscle and the nerve supplying it. 

There are several reasons that a reverse shoulder replacement may not perform as well as planned. The main ones include loosening of the implant, infection, and fracture. It is very uncommon for the deltoid muscle to ‘rupture’ as it is such a big muscle made up of three different muscle bellies. The surgical approach that I use also preserves the deltoid muscle so that it is not cut. Furthermore, I utilise 3D planning software prior to implanting a shoulder replacement and Patient Specific Instrumentation during the procedure to ensure precise implant placement. This is another way of minimising the risk of complications.

In the setting of a shoulder replacement not functioning as expected, further thorough investigation is warranted. This may include blood tests and further scans to rule out loosening, infection and subtle fractures. Nerve tests may also be suggested if there is concern that the deltoid muscle is not functioning properly. 

Once a likely diagnosis has been made for your specific situation, then a tailored management plan can be made. Very uncommonly, a revision procedure may be required to address the problem and restore function. 

I have answered your question in general terms as I am not aware of the details of your situation, but I hope this helps to clarify things for you.  

Shoulder pain when raising the arm

Both my shoulders have started giving me a lot of pain when I try to raise them

Pain with overhead arm movements or when trying to raise the arms is a common shoulder complaint. It can be due to a variety of causes which can be sometimes related. The most likely causes are shoulder bursitis and impingement, rotator cuff tear, and shoulder arthritis.

Shoulder bursitis and impingement is caused by an abnormal inflammation involving the bursa which sits between the ball of the humerus (arm bone) and the shoulder blade. It normally helps to cushion the shoulder tendons from the overlying bone of the shoulder blade. See my article here for a detailed diagram of this: https://drraymondyu.com.au/shoulder/conditions/subacromial-impingement/ 

When the bursa becomes inflamed and bone spurs have developed, trying to raise your arm can cause a great deal of pain. This pain is called impingement pain, and the motion of lifting your arm through the pain is called the ‘painful arc’. 

A rotator cuff tear can also be painful when related to impingement and bursitis. The rotator cuff are the shoulder tendons which help lift and rotate your arm. Having bone spurs and impingement can be one cause of rotator cuff tears over time, which is why these problems are can be related. Read more about rotator cuff tears here: https://drraymondyu.com.au/shoulder/conditions/rotator-cuff-tears/ 

Finally, shoulder arthritis can cause pain when raising the arms, however for the pain to develop in both arms at the same time is a bit unusual. Arthritis is a process describing the damage and deterioration of the cartilage within the shoulder joint. Over time, bare bone is exposed underneath the cartilage, and causes pain with movement. Some options for management are outlined here: https://drraymondyu.com.au/shoulder/conditions/arthritis-2/ 

Whatever the cause of the pain, it is best to visit your GP for an initial assessment and commencement of simple treatment modalities. If necessary, you may require a referral to see an Orthopaedic Shoulder Surgeon for further assessment and management. 

I hope this has helped give you a brief understanding of the possible cause of your problem. 

Rotator cuff tear with pain - will it heal?

I got a Rotator Cuff tear ( self diagnosis courtesy of Google) a couple of months ago. It is only painful with certain movements. It seems to be healing. Will it heal over time?

The rotator cuff is made up of four tendons which extend from the muscles of the shoulder blade, and attach to the head of the arm bone (humerus). They are responsible for elevating the arm above your head, as well as rotation of the arm. The rotator cuff can get torn as a result of an injury such as a fall or dislocation, but more commonly occur over a longer period of time.

Risk factors include:

  • Genetics
  • Reduced blood flow to the tendon
  • Age
  • Bone spurs 
  • Shoulder instability and repetitive overload

What you have described in terms of pain with certain movements is certainly one symptom of a rotator cuff tear. Other symptoms include weakness with arm elevation or rotation, dull aches at night, and limitation of movement. Often there are concurrent issues in the affected shoulder, including inflammation of the biceps tendon, bursitis and arthritis. These can all potentially contribute to the painful shoulder.

A thorough assessment by your GP or Orthopaedic Shoulder Surgeon can diagnose most rotator cuff tears. These can then be confirmed with ultrasound or magnetic resonance imaging (MRI). 

Information from your specific history, examination and further imaging will help determine the likelihood of the cuff tear healing with time. Most small, partial thickness tears can heal with time, and with non-surgical management. Non-surgical management includes: rest, a graduated physiotherapy program, analgesia, and a single steroid injection. Read more about the management of rotator cuff tears here: https://drraymondyu.com.au/shoulder/conditions/rotator-cuff-tears/ 

Surgical repair should be considered for larger tears, or in patients who have ongoing pain and loss of function despite non-surgical management. Surgery involves a keyhole procedure using modern arthroscopic techniques to repair the torn tendon back to its normal position. Bioabsorbable anchors are used along with high-strength surgical tapes to ensure a strong repair is achieved. Learn more about rotator cuff repairs here: https://drraymondyu.com.au/shoulder/surgery/rotator-cuff-repair/ 

I hope this has helped to answer your question. 

 

Disclaimer: Please note that this is general advice only - for more information, please consult your regular doctor, or obtain a referral to see a specialist orthopaedic surgeon. 

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