While the Tin Man is a memorable literary character, he isn’t the most aspirational figure when it comes to joint health. But if you constantly feel like you are having to “oil” your shoulder pain while suffering through stiffness you may find more similarities with Dorothy’s metal mate than you would prefer.
The fundamental problem with an arthritic shoulder joint is that it does not have the normal cartilage that provides cushioning and lubrication to a joint. While we cannot regenerate cartilage, we have a variety of medical treatments ranging from anti-inflammatory pain relievers to biologic treatments, each with different roles.
You will have several options, including shoulder replacement surgery, to help you ease on down the road with less pain and more flexibility. To help you understand these options, we talked to one of the expert orthopedic surgeons at Southwest Orthopedics and Sports Medicine in St. George (our own orthopedic wizard if you will):
So you have shoulder pain, what next? What happens first?
Dr. Leitze says: “It is wise to start with a clear and correct diagnosis. One of the keys to treating any Medical problem is application of the right treatment to the right problem.”
How will my doctor understand and diagnose my unique shoulder pain?
Dr. Leitze says: "For a musculoskeletal problem, diagnosis is rooted in a careful history and a proper exam from a physician that deals with these problems. An x-ray can be helpful when evaluating the shoulder and can often clarify if it’s arthritic or not. There are lots of factors that can lead to joint pain in the shoulder. Outside of arthritic conditions, there are conditions related to the soft tissues, like bursitis, tendonitis, rotator cuff tear, labral tear, and biceps tendinopathy. As each of those may have a different treatment; diagnosis is key.”
What is a rotator cuff?
Dr. Leitze says: “Our shoulders have a layered structure of muscle. The outer shoulder muscle is the deltoid. That's the largest one you see right under the skin. Underneath that deltoid muscle is a layer of four smaller muscles. They make a cuff of tissue that surrounds the shoulder joint. And the job of those four individual muscles is to help rotate and stabilize the shoulder. That's where that term 'rotator cuff' comes from.”
A rotator cuff tear can come in two different forms.
- Partial tear: A partial tear is similar to the worn knee of your favorite pair of jeans. While your knee may not be fully exposed, over time the fabric gets thinner, the threads get sparser, and your jeans barely hold together. This is similar to how the tendons around your shoulder wear down, providing less and less support to the joint.
- Full tear: If you bought a pair of jeans with holes showing your entire kneecap, this would be like a full tear. The tendon is no longer covering the ball joint of the shoulder or supporting movement.
What should I try first to relieve shoulder pain?
While the Tin Man only had one road to skip down to get to his destination, each individual suffering from shoulder pain may have a different treatment journey. But the first treatments commonly recommended for shoulder pain include anti-inflammatory pain medications and physical therapy.
Dr. Leitze says: "Many patients try the over-the-counter anti-inflammatory treatments that most all of us are familiar with. Advil, Ibuprofen, Aleve, and others can be helpful in the early stages of arthritic or other inflammatory conditions. Often patients have started these before I see them because most everyone can access these treatments.
From there I suggest physical therapy. Home-directed exercises or formal physical therapy are an important part of looking after an arthritic or painful joint. For the shoulder, stiffness is a big impact of arthritis or cuff disease. Our shoulders have an amazing range of motion when they're healthy and normal. Because of that motion, maintaining function in a painful joint with a routine stretching program is very helpful. If we can medicate the shoulder to reduce pain, then strength work is also useful."
What are other treatment options for shoulder pain?
If pain intensifies or returns following one course of treatment, your care team will continue to try different methods to make you comfortable. If anti-inflammatory medications stop easing the pain, the next option to consider is steroid injections or shots. Cortisone or other injections like hyaluronic acid can relieve pain for several weeks or months.
Dr. Leitze says: "If pain becomes more intense, many patients will come see us for a time-honored, well-studied, and effective anti-inflammatory treatment: corticosteroid injection, sometimes called a cortisone shot. These are temporary measures to take away pain and inflammation. Many times these injections can reduce pain and inflammation that allow a patient to participate in other parts of non-surgical treatment for joint pain, like therapy activities. Recently, awareness of Platelet Rich Plasma and Stem Cell injections has grown. These treatments are in the experimental phases, so stay tuned."
When should I consider shoulder joint replacement surgery?
Dr. Leitze says: “The primary reason to consider joint replacement (or most surgery) is pain that is 1) otherwise untreatable with medical or therapy methods and/or 2) a significant interference with activities of normal life, and you are capable of the rehab and recovery to get the benefit. If you have pain when you hold the phone to your ear, get the laundry out of the dryer, or swing a golf club, we can help with that. If you have trouble sleeping because of throbbing pain when you change positions, or have a dull ache that wears you down let us help. When your normal daily life is impacted, it’s time to look at your options. Surgical timing boils down to limitations that are unable to be managed with conservative non-surgical treatment.”
What happens during shoulder replacement surgery?
Metal is the new black, at least that is what the Tin Man told us. During shoulder replacement surgery, a surgeon replaces the damaged shoulder joint with an artificial joint, usually made of metal, ceramic, or plastic. There are a few different types of shoulder replacement surgery, depending on the condition of the shoulder and the rotator cuff (the tendons and ligaments surrounding the shoulder joint).
- Traditional anatomic replacement: If the rotator cuff is in good shape, then you may just need to replace the joint or place a cap on it to compensate for missing cartilage.
- Reverse shoulder replacement: A reverse shoulder replacement switches the placement of the ball and socket. This approach stabilizes the shoulder, making it ideal for those with a damaged rotator cuff.
Dr. Leitze says: "Having a joint replacement surgery is a very individualized treatment. After the x-rays, physical therapy, or the physical exam, many patients realize that they don’t need a joint replacement. It really comes down to this: when your pain and disability is such that it outweighs the emotional hurdle, concern about risk, and recovery that comes along with surgery, that’s when patients decide to have surgery for their shoulder.
That said, when we use the term 'shoulder replacement,' it conjures up all sorts of thoughts and images. A better term for patients would be to describe it as a shoulder resurfacing. The surgery covers the shoulder socket with a material to substitute for the lost cartilage and removes a small portion of the shoulder ball to be replaced with a metal substitute. These new surfaces then become the weight-bearing substitute for the lost cartilage. This is how a shoulder replacement achieves the necessary pain relief."
While finding a solution to your shoulder pain may not be as instant as clicking your heels a few times, experts like Dr. Leitze at Southwest Orthopedics and other Intermountain orthopedic surgeons can help you find your own road to a pain-free life.
And don't worry, we will leave the singing and dancing to the Tin Man.