Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.  (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)

This week, she calls on the expertise of Dr. James Wyss, M.D., P.T., an Assistant Attending Physiatrist in the Department of Physiatry at the Hospital for Special Surgery in New York City, for a primer on shoulder-replacement therapy for an injured athlete.

 

Dear Dr. Pat:

I am 48 and very athletic. I play tennis and golf, and ski obsessively. I certainly have tried to stay fit, but I have injured my right shoulder twice: once in a ski accident, when I broke my upper arm near the shoulder joint, then about six months later when I developed right-shoulder pain from returning to tennis (four times a week). It has been six weeks since I have been able to do any sport, and I am going out of my mind.

I saw an orthopedic surgeon last week, and he told me that I needed a shoulder replacement. I never had physical therapy for my right-upper- arm fracture; it healed, and no one told me to take it easy when I returned to sports where I use my arms and shoulders. The orthopedist told me that I have “overuse syndrome” and that I have “bone on bone” in my shoulder. Is shoulder replacement the first and only option for me? I am, by the way, very flexible, if that is of interest. If I must have a shoulder replacement, should I have it done in my small city (100,000), with no medical school, or should I seek a specialist who has lots of experience? Does physical therapy help after shoulder replacement? Will I be able to return to my athletic passions?

It seems to me that lots of women I know in their 40s and 50s are having serious shoulder problems. Does hormonal change have an impact on this, or is it just age and bad luck?

Marcia

 

Dr. Wyss Responds:

When I began practicing physical therapy in the 1990s, I wasn’t very impressed by the results of total shoulder replacements (TSR), also known as total shoulder arthroplasty (TSA). I saw patients recover quickly and very well after total hip and knee replacements, but not after total shoulder replacements. The surgery relieved their pain, but didn’t significantly improve their function.

Since then I have seen steady progress in the results of total shoulder replacements. Currently, in my physical medicine and rehabilitation (PM&R) practice, I see patients whose care I share with my orthopedic colleagues get pain relief and functional improvement following total shoulder replacements. As a physiatrist who cares most about improving quality of life and function, this is now a surgical procedure that I can recommend to specific patients.

Although I have seen steady progress in outcomes after TSR, that doesn’t mean that a total shoulder replacement is the “first and only option” for shoulder osteoarthritis. Candidates for a TSR should have pain and impaired function due to severe shoulder osteoarthritis and should have tried and failed more conservative care.

 

TSR-osteoarthritisX-ray showing arthritis of the shoulder joint. (Image used with permission from Hospital for Special Surgery)

 

“Conservative care” includes activity modification (limiting overhead sports, serving underhand as opposed to overhand in tennis and volleyball); medications to relieve pain and inflammation (acetaminophen, NSAIDs, etc.); physical therapy to improve function, and possibly a trial of shoulder injections. Cortisone injections often relieve pain and inflammation, but may provide only temporary relief (less than 3 months). Hyaluronic acid injections (joint lubricants) are considered off-label use for the shoulder, but some patients have good results, finding them and/or other non-operative treatments to be an acceptable alternative to surgery.

If you do decide to proceed with shoulder replacement surgery, then I would recommend obtaining two surgical opinions, since technique and prosthetic choice may differ among orthopedists. Shoulder replacement options include traditional TSR, reverse TSR (reverses the position of the ball and socket), and resurfacing.

 

TSR-Anatomic-replacement1X-ray showing anatomic total shoulder replacement. (Image used with permission from Hospital for Special Surgery)

 

TSR-reverse-arthropathy-afterX-ray after reverse shoulder replacement – the reverse of the anatomic total shoulder replacement. (Image used with permission from Hospital for Special Surgery)

 

I would also recommend a surgeon and surgical center with a great deal of experience. This is very important with TSR, since many fewer replacements are performed on the shoulder, compared with the knee and hip (the American Association of Orthopaedic Surgeons reports on its website 50,000-plus shoulder replacement per year versus 900,000-plus for knee and hip). The technical experience of your surgeon and his or her team can make the difference between an acceptable versus an exceptional outcome. In my opinion, physical therapy (PT) is important before and after surgery. Prior to surgery, I would recommend participating in PT to improve shoulder strength, especially to improve scapular [shoulder-blade] strength and control. Obtaining better strength and function prior to surgery should result in better post-surgical outcomes. This phase of rehabilitation is known as prehabilitation, or prehab. After surgery, your surgeon will guide your postoperative rehabilitation, usually with the supervision of a physical therapist. Resuming prior athletic activities after TSR is possible. Studies have demonstrated a successful return to routine fitness activities and sports such as swimming, tennis, and golf.

Shoulder pain is very common in middle-aged men and women, and is one of the five most common reasons to visit a musculoskeletal medicine practice such as mine. By middle age, many people develop muscle imbalances, poor posture, impaired control of the scapular, and the rotator cuff begins to degenerate; this is also known as rotator cuff tendinosis. These changes usually lead to a gradual (at times a sudden) onset of shoulder pain. Although hormonal changes may play a contributing role and joint pains may be associated with menopause, I’m not aware of a direct link between hormone changes and the development of shoulder pain. In your case, I would consider post-traumatic osteoarthritis of your shoulder as the cause—meaning that the skiing injury and fracture you suffered may have been the initial injury to the smooth cartilage that lines the shoulder joint, and then gradual degeneration of the joint led to early “bone on bone” osteoarthritis.

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  • Kathy F June 2, 2014 at 1:07 pm

    Nora Ephron refers to frozen shoulder in her book about her neck and other things she hates about aging.
    After more research & going to approximately 4 diffdrent traditional doctors, I ultimately went to an acupressurist who healed my first frozen shoulder, including decreased range of motion and lack of sleep, through intense scar tissue manipulation, after explaining that in China, this is called
    “50 year old woman syndrome” my approximate age at the time.
    She then helped me with my second frozen shoulder,in the other shoulder, a couple of years later.
    Both were caught early on when I realized I felt pain & had trouble with range of motion; i.e, opening doors, hooking my bra, reaching to try on clothes in a fitting room, incurring much pain during sleeping.
    I believe the traditional doctors didn’t understand what I had because I had no injury or other identifiable frequently cited onsets and I had caught and questioned the symptoms – early in the debilitating process. My symptoms did not manifest according to the most extreme signs that most traditional doctors are used to seeing. I do believe hormones often cause frozen shoulder in females. BTW…my acupressurist is blind, was trained in China and is superbly gifted & wonderful – as attested to, not only by me, but the many layers of referrals that I and others have sent to her over the last 7 – 10 years, for many movement, pain issues.
    I believe doctors should truly touch their patients in so many ways before prescribing shots and or surgery.

    Reply