Ask Us Anything About… Shoulder Pain

Shoulder pain has many causes – but there are also a lot of treatment options to help people find relief and get back to living a normal life. We learn more from Dr. Aman Dhawan, a sports medicine specialist at Penn State Health.

March 7, 2019 Penn State Health News
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Transcript

Description – The video begins inside an office at Penn State Health Milton S. Hershey Medical Center. Two people are standing next to each other. Standing from left to right is Scott Gilbert and Dr. Aman Dhawan.

Scott Gilbert – From Penn State Health, welcome to Ask Us Anything About Shoulder Pain. I’m Scott Gilbert. Shoulder pain is a common complaint. And it has many causes. And getting it fixed is important because of how often we use our shoulder joints even just to perform common everyday tasks. Here to tell us more about shoulder pain, how it’s diagnosed and how it’s treated is Dr. Aman Dhawan. He’s an orthopedic surgeon here at Penn State Health. Dr. Dhawan, thank you so much for your time today. Let’s talk a little bit about just how often we do use shoulders, maybe without even realizing it. In fact, I kind of forget I have shoulders sometimes I think unless they’re in pain.

Dr. Aman Dhawan – Yeah. That’s a good point, Scott. So, you know, the one thing about shoulders is we don’t walk on our upper extremities. And as such, people will be often much less tolerant of problems in their lower extremities like their hips or knees. Whereas shoulders, because you don’t take steps and you don’t walk on them, often you’ll live with those problems for a while until those problems become daily, nightly if you will with activities such as occupation or activities like sports. And so, patients will deal with shoulder problems much longer than they will in their lower extremities mostly because of that weight bearing access.

Scott Gilbert – Well, let’s talk about the structure of the shoulder, a little bit about what’s going underneath the skin. I guess this is kind of– this would be the equivalent of my right shoulder right here, right?

Dr. Aman Dhawan – That’s right.

Scott Gilbert – That’s the– Well, you could tell us what the various parts are. But just so people have a bit of an understanding of what’s going on again under the skin there in this we call a ball-and-socket joint?

Dr. Aman Dhawan – Yeah, absolutely. So the one thing about the shoulder is there’s actually a number of different areas here in the shoulder that can cause pain and problems. And most people think about the true ball-and-socket joint. If I take this muscle out of the picture and you can see the humeral head and the glenoid here, the typical ball-and-socket if you will. But really, the shoulder is this entire area including in the back, the shoulder blade, the scapula we call it, as well as up top here where the clavicle comes in and meets the shoulder we call the AC joint. All of these three areas are considered actually part of the shoulder and can cause problems. When we look at the shoulder on the side, what we see is indeed that cuff of muscle and tendons that we call the rotator cuff. And it starts in the front here, the subscapularis, continuous up top with the supraspinatus, the infraspinatus, and back to the teres. But this semicircular cuff of muscles and tendons is what often causes, so much problems.

Scott Gilbert – And then in fact, we’re going to talk about the various types of shoulder pain. Let’s start with the rotator cuff because when we hear rotator cuff injuries, they happen to everyday people, they happen to professional athletes, and everyone in between. What causes them?

Dr. Aman Dhawan – Yes. So rotator cuff is usually– or usually seen in two sort of instances. The most common is the overuse or a chronic type pain. Or– And it can be an acute on a chronic injury, meaning someone can have some kind of simmering shoulder issues for a while and then have a fall or something that kind of is the straw that broke the camel’s back. And these are the common types of rotator cuff injuries. There’s a well demonstrated studies that demonstrate decreased blood supply and decreased human capacity over where the rotator cuff inserts into the ball. And as such, this is particularly prone for overuse injuries, attritional injuries, and then eventually failure. And this is most type of rotator cuff tears.

Scott Gilbert – Are certain people at more risk for rotator cuff tears whether it’d be age, gender, et cetera?

Dr. Aman Dhawan – Certainly we see two types of people. Some people, it’s inherent and it has to do with some of their boney anatomy. And specifically when you have spurs up on top of the rotator cuff in this bone here called the acromion, and that can just create a friction phenomena and then just slowly wear down that rotator cuff, particularly, at its insertion on the ball. The other are people that create environmental challenges to their rotator cuff including smokers. Even people with high cholesterol have been shown to have increased rotator cuff problems, obesity and such. So there are certainly instances where you have control over what you can do as far as rotator cuff health and there’s others where your boney anatomy from where– from what you are born with is a problem.

Scott Gilbert – You’re watching Ask Us Anything About Shoulder Pain from Penn State Health. I’m Scott Gilbert. He is Dr. Aman Dhawan, an orthopedic surgeon here. We welcome your questions and your comments. Just put them in the comment field below this Facebook post and we’ll make sure we get your answers. Whether you’re watching this video live or even on playback, we’ll put some answers for you in the comment section. So rotator cuff tears, just one of many types of injuries and many types of causes of shoulder pain. Let’s talk about arthritis and osteoarthritis. What’s going on there?

Dr. Aman Dhawan – Yeah, absolutely. So the shoulder is a diarthrodial joint, meaning it’s a joint two bones and it has cartilage covering that creates a frictionless or low friction surface for movement. And just like the knees or the hips or the ankles, the shoulder is prone to osteoarthritis which essentially it’s just a wearing down of the cartilage. There are several different kinds of arthritis. Osteoarthritis is by far the most common. Osteoarthritis is essentially when that cartilage and the services of the ball and/or cuff breakdown and essentially you start to get increased friction which creates inflammation, pain, stiffness, and problems.

Scott Gilbert – And bursitis, what’s that about?

Dr. Aman Dhawan – Yeah. So bursa– We have bursa all out through our body, Scott. So, bursas exist anytime you have two things moving across each other. And in the shoulder, there are a ton of them. The most common bursitis that we see is subacromial bursitis which again referring back to this model here exists up here at the top of your shoulder essentially right above the rotator cuff but below this bone, the acromion. And that bursa creates a really thin fluid layer that allows movement to occur with low pain and low friction. When you start getting increasing friction there or inflammation, you start getting problems. And that bursa in of itself despite the fact that it’s there to decrease pain can actually be the problem in of itself.

Scott Gilbert – You know, I’m starting to understand whether such thing as a shoulder specialist like yourself, it’s a very complex joint, isn’t it?

Dr. Aman Dhawan – It is.

Scott Gilbert – Any other common causes of shoulder pain that we haven’t touch on yet?

Dr. Aman Dhawan – Yeah, absolutely. So, you know, when we talk about shoulder pain, you really see two demographics. You see kind of the young shoulder patient under 30 and it’s often due to overuse type injuries, often traumatic injuries like sports. You’ll see shoulder dislocations and tears of this cartilage covering around the cuff called the labrum. And so, these are types of injuries that we see often in the younger patients of that labrum itself. As you start to get older, we start to see some other patients in the other categories, osteoarthritis for instance, which is wear and tear, rotator cuff problems. The most common or the average age of a rotator cuff issue is 60 years old. And then we start to see problems with up here where the AC joint is, and where other problems can occur to include inflammation, osteoarthritis and pain. And so, you know, there’s a lot of anatomy in a really small area here, Scott. So a little bit different than let’s say the knee or the hip, and this is why you can have so many different causes of shoulder pain and problems. And this is why we spend so much time trying to vet this out with physical exam, X-rays, MRI, injection, so on so forth.

Scott Gilbert – As I mentioned, we welcome your questions for Dr. Dhawan. Just put them in the comment field below this Facebook post. That’s what has Cindy has done. She’s asking and I’m probably going to butcher the pronunciation but she’s asking, what is os acromiale?

Dr. Aman Dhawan – Os acromiale.

Scott Gilbert – Oh, yeah, that was my next guess.

Dr. Aman Dhawan – Yeah. Great question, Cindy. So essentially os acromiale is when you have this area here of the acromion which is part of your scapula bone that sits on top of the rotator cuff. And this acromion here becomes fused. It actually starts at several bones early on in utero and then fuses to form what we see solidly here. Os acromiale is when this does not fuse properly. And so, you’ll still see a separation of parts of this acromion and it almost looked like ossicles. It looked like separated bones. But it’s not really separated, it just never fused. And so those separated pieces or those unfused portions can cause problems because those alone can push on tendons, for instance the rotator cuff, and can cause problems into itself.

Scott Gilbert – So what do you do to cure that?

Dr. Aman Dhawan – So, you know, initially like most things around the shoulder, they usually don’t require surgery. You know, a lot of things around the shoulder again are overused types of phenomenon. And even phenomenon like this that is a structural issue often what’s the painful about it? It’s not the os acromiale. It’s what it’s doing to the rotator cuff. And so, we treat that. And we treat that with a combination of anti-inflammatories, physical therapy, sometimes injections, essentially trying to mitigate the pain generator. The os acromiale will still be there. But once that pain generator is mitigated, this may never come back. Now, if this is a problem that continuous to rear its ugly head, that’s when you may consider surgery for that to include excision of that os acromiale or fusion of it.

Scott Gilbert – You’re watching Ask Us Anything About Shoulder Pain from Penn State Health. Our next question comes to us from Shawn [assumed spelling]. He’s asking about bone spurs. He says, how about bone spurs and tearing into muscles? Is that a common problem?

Dr. Aman Dhawan – Yeah. So that’s kind of what we’re talking a little bit about earlier. That’s a great question. And essentially, that’s– these bone spurs that people typically are talking about are the ones underneath the acromion. So again, this acromion as you can see creates a lot of havoc. And it’s partly because of its position right over the rotator cuff. So this, if we look at it on its side here, this acromion, the one that we see here is nice and flat and smooth. It often can get spurs or unevenness underneath and that creates, as you can see, friction to the muscles and tendons just underneath. That phenomena can create an outside in tearing phenomena and extrinsic mechanism to tearing the rotator cuff that eventually cause it to fail.

Scott Gilbert – I’m curious about some other possible causes and sometimes concerns about backpacks causing back pain especially for children even in school at a young age. Can that cause problems with the shoulder too?

Dr. Aman Dhawan – Yeah, absolutely. I mean, typically backpacks and shoulder bags don’t cause structural issues to the ball and cuff themselves, but again as you can see this anatomy here has a lot of anatomy additionally that’s around this. For instance, the deltoid muscles, the trapezius, and all of these are prone to overuse like everything else. If you normally carry a heavy bag on one shoulder, you’re prone to an overused injury of those muscles. I get it myself when I’m carrying my computer around and such. Typically, they’re not a structural problem. I mean, you know, you shouldn’t worry that you’re going to cause some sort of irreversible issue. But it never feels great to be sore. It never feels great to be in pain. So think about lightening your bag, thinking about shifting shoulders. If you are wearing a backpack, try wearing both straps, you know. And again, it always behooves us to try to lighten those loads. I see sometimes these kids are walking to school. I have four children and all them go to Derry Township schools. They walk to school. I see some of these kids have backpacks that are, you know, as big as them which is four or five big textbooks in there that adds up. So if you can, try to lighten those up. And I think the school has done a really good job as far as trying to go into electronic books and such and trying to lighten that kind of physical load. But as much as you can, that’s always a good idea.

Scott Gilbert – Here’s a good question from Lee. He’s asking what causes crunching noises in the shoulder when and with movements? So moving your shoulder, if you hear those pretty unsettling noises, well, what could be behind that?

Dr. Aman Dhawan – Yeah, absolutely. So, colloquially we called them Rice Krispies.

Scott Gilbert – Is that the medical term?

Dr. Aman Dhawan – It’s not. So, surgically or medically, we call it crepitus. So, it’s essentially that popping or crunching type noise, Rice Krispies if you will. And it can come from a number of different areas. So the most common areas that it comes from is typically that bursa that we were talking about, that small little layer of fluid that sits on top of the rotator cuff and helps it glide against bones like the acromion, this bone here, over here, the coracoid and the scapula. When that bursa becomes inflamed or scarred in, and with movement now, you can imagine those muscles are now going to click and crack as they move and glide across this kind of scarred in, uneven type tissue. And so, that’s a very common cause. Another very common cause is frankly osteoarthritis. So obviously, when the cartilage bearing surfaces start wearing down and they start becoming uneven, those two surfaces are going to sound like a car driving over a bumpy road.

Scott Gilbert – Sure. You know, I’m curious when it comes to causes another thing is repetitive movements at work. I imagine that could lead to, especially for people on manual labor jobs who are in those jobs for decades could that lead to things like osteoarthritis?

Dr. Aman Dhawan – For sure. And that’s why a big area now is ergonomics in terms of trying to control your workspace the best you can. You know, some people can’t and unfortunately, you know, they have to kind of end up pushing through this. And it can create issues in terms of potentially putting them at risk for injuries like rotator cuff or osteoarthritis or AC joint arthritis, biceps tendon issues, labral tears, so on so forth. So, you know, no question, you know, if you feel shoulder pain, you shouldn’t ignore that. And oftentimes, it’s a matter of reconciling your environment and managing the ergonomics. Oftentimes, it requires further treatments. Like I said like the anti-inflammatory medicines, physical therapy or other non-operative treatments, and then occasionally surgery.

Scott Gilbert – So Lori [assumed spelling] has a question. As we move toward those treatment options into the discussion about those, she’s asking, what options exist and are available to patients other than oral medications? So, you know, perhaps we could go over a few of the different types of treatment, when you use oral medications, when you use surgery. I mean, it’s kind of a big question.

Dr. Aman Dhawan – Yeah.

Scott Gilbert – It’s about five or six questions in one at least. But, you know, what are those– I mean as a practitioner, when do you think, OK, this is good for medicine but this might be better for surgery?

Dr. Aman Dhawan – Yeah, absolutely. So, you know the concern sometimes with oral medications is that they’re systemic, right? So if you take a medicine through your mouth, it’s going to obviously impact your shoulder but it may impact other tissues as well and some people aren’t comfortable with that. And so, there are treatments that are localized to the shoulder itself, simple things like topicals. For instance, there’s a topical anti-inflammatory called Diclofenac or Voltaren Gel that works quite well. You know, different people have different effectiveness of that but that is an option for you. Other topicals include lidocaine patches or Icy Hot Gels. The Bengay types can also often be effective. You know, simple ice is probably underutilized. And in study after study, it’s been shown ice to be very effective both as an anti-inflammatory and an analgesic. So I think, you know, people don’t probably use ice enough and I’m a strong proponent of the ice amongst other treatments. And then we get into treatments like injections. Obviously more invasive but there are different injections that we can provide, the biggest of which is corticosteroid which is essentially a very powerful anti-inflammatory injected locally, directly to where we want it to go. Often, we’ll do this under ultrasound, so it’s image-guided and we make sure it gets to exactly where we want it.

Scott Gilbert – Are there certain types of shoulder pain and diagnosis that typically result in surgery versus medication, or is it really just very different depending on the case?

Dr. Aman Dhawan – So, it’s always case-by-case basis for sure. But there are definitely certain diagnoses that require surgery more often than others. For instance, a labral tear in a younger patient, again under 30 patient, especially, if it’s due to a traumatic injury, you know, a dislocation for instance or a major trauma like a motor vehicle or sports, football, what have you, that can often require surgery because that’s not something that likely is going to get better. And this is someone that’s going to have to live with that shoulder for another 50, 60 years and often wants to stay active through their 30s, through their 40s, 50s, 60s, 70s. So, you know, those aren’t ones that you want to ignore and you want to fix the problem. Rotator cuff issues often are what we end up doing surgery for also, though many of them can start with non-operative treatment. But if they become refractory to that or the tear is fairly large, those are ones that, again, are not going to be reconciled with non-operative treatments. And those are ones that we do like to operate on in order to, A, prevent further tearing, B, prevent retraction, and C, get the patient back on to a healthy lifestyle and an active lifestyle. So those are issues that you will often see surgery for.

Scott Gilbert – How about shoulder replacements? As with the other joint replacements, are there different degrees or levels of what actually constitutes a shoulder replacement?

Dr. Aman Dhawan – Yeah, absolutely. I mean the two major shoulder replacement categories at this point are a typical total shoulder arthroplasty, TSA, or a reverse total shoulder arthroplasty. And the reverse total shoulder arthroplasty is less common. Essentially, these are in specific instances most commonly because of a patient who had a shoulder and their rotator cuff has become incompetent in addition to their severe osteoarthritis. And so, the mechanics the engineering of the implants has to be a little bit different to compensate for that. Typical total shoulder arthroplasty replacement is we take a portion of the ball off and replace it with a metal ball and we take it– we replace the arthritic cup, the glenoid with a plastic cup. And so, this is a typical total shoulder arthroplasty.

Scott Gilbert – You mentioned good old-fashioned ice is a good treatment sometimes. And I’m wondering if sometimes that could be used, you know, at home in conjunction with things like NSAIDs, you know, those over-the-counter pain medications.

>> Absolutely. I think ice and NSAIDs are really an outstanding two ways to try to decrease particularly people who have, one, acute injuries, but two, even people that have chronic injuries. And again, you know, oftentimes, when we see patients in clinic for a shoulder problem, you know, the first thing that they want to know is, is this really bad and do I need surgery? And it’s rarely that you do. And most often, we’ll start with non-operative modalities to include physical therapy, NSAIDS. And the over-the-counter NSAIDs are really outstanding, Ibuprofen and Aleve. I have access to probably any NSAID I want. Obviously, I can ask any one of my partners to prescribe and a prescription of anti-inflammatory. I use Ibuprofen. It’s outstanding. Ice is also very underutilized. And ice again has been shown in study after study to be extremely effective, maybe more effective than some of the NSAIDs, and a great analgesic.

Scott Gilbert – Great to know. You’re watching Ask Us Anything About Shoulder Pain from Penn State Health. We welcome your questions for Dr. Aman Dhawan. He’s an orthopedic surgeon here at Penn State Health and he’s obviously got the answers to those questions. So feel free to add those in the comment field on this Facebook post and we’ll be sure to pose them to him you know. You know, you mentioned briefly physical therapy. Now, I’m wondering when that comes into play. So sometimes, physical therapy can be the treatment, not just something that happen say after surgery.

Dr. Aman Dhawan – Yeah, absolutely. So, you know, you see all the kind of soft tissues that are surround the shoulder and the bones of the shoulder. And so, you know, physical therapy really has come along a great deal. And, you know, it’s not just about stretching and movement, but there’s a number of techniques they can use including ultrasound, including massage, including electrical stimulation, so on so forth that we call modalities that can go a long way in terms of reconciling shoulder pain. And if it’s really mostly a soft tissue injury, you know, physical therapy may be all you need.

Scott Gilbert – And I’m curious, obviously you’re a surgeon but I’d like to get your take on other perhaps less traditional methods of treatment such as acupuncture, chiropractic care, other alternative methods. Do some of those– I mean some people say that they help their pain? I know, again you’re a surgeon, you might be biased–

Dr. Aman Dhawan – Yeah.

Scott Gilbert – —but I mean are there cases where you’ve seen that work?

Dr. Aman Dhawan – Yeah. So, you know, interesting enough, I’m of Indian background. I was born here in Baltimore but my parents were born in India and are very traditionally Eastern medicine kind of culturally and oriented. And, you know many of those treatments, you know, for instance acupuncture, chiropractic, and there’s a number of treatments in this kind of algorithm that are not traditional Western medicine have been shown to be very effective. And so, you know, I have the benefit of being able to be, you know, Western trained. I’ve been trained at some of the best institutions in the US, but I have parents that are obviously traditionally Indian, and so I’ve, you know, heard a lot from them. And so, I tend to keep an open mind about it. I think– To be honest with you, I think acupuncture and chiropractor or chiropractors have a wonderful role and I think, you know, one thing that they often do better than we do as physicians is the hands-on time with the patients. I do think that there is some data to suggest that there’s also some therapeutic aspects to that. And so, what I tell my patients, you know, who have chiropractors or nutritionists and/or nontraditional Western medicine philosophies is there’s really no harm in doing most of those. And if it makes you feel better, it’s hard to beat that. And so, I try not to fight that. I try to work with that. And I think you’re seeing that philosophy more and more in Western medicine. So the short of it is, is that I’m in favor of anything that makes your shoulder feel better. And if that works for you in terms of acupuncture or chiropractic care, I’m all for it.

Scott Gilbert – Makes good sense. We have another question now from Cindy. She wants to know, what is shoulder impingement?

Dr. Aman Dhawan – Yeah, great question, Cindy. So there are two types of shoulder impingement. The most common type of shoulder impingement is when that rotator cuff, and again to kind of go back to this model, when that rotator cuff pushes up or impinges on that acromion bone, all right? And it might be a problem with the rotator cuff, it might be inflamed and thickened, and that may cause obviously a volumetric issue, or it might be from spurs or an abnormal shape of the acromion which also cause a volumetric issue. But the idea is as the shoulder comes up into abduction here or forward flexion. You see this space closed down which creates pinching or impingement. And that’s the most common type of impingement. We call it subacromial impingement. There’s another type of impingement that we also call internal impingement or posterior impingement. And essentially, this is more we see in throwers, especially young throwers. And what happens is as young thrower shoulders, their soft tissues evolved and changed, because of the repeated throwing they start getting pinching in the back where the labrum sits up against the rotator cuff. And so, they get changes in the capsule and in the anatomy inside the ball and cup area that pushes the ball back, pushes that labrum up against the back of the rotator cuff. This is a more specific phenomenon. Again, this is more than throwers. You see it very commonly in pitchers. It’s also associated with range of motion deficits. But those are the two major types of impingement.

Scott Gilbert – You know, as a father of a young pitcher though, I appreciate that because we hear a lot about elbow pain, like watch out for that elbow, protect that arm. But the arm doesn’t– You know, it doesn’t stop here. You got to watch out for shoulder pain in young athletes too.

Dr. Aman Dhawan – Oh, absolutely. So we just published some really great data looking at thousands of pitchers and looking at risk factors for shoulder and elbow injuries in youth baseball players. And this all stems, my son plays baseball at a high level and there’s a lot of gestalt out in the community and, you know, in the press that tells you do this or don’t do that. And not a lot of it is data based. So we wanted to look at that. We published that last year looking at thousands of athletes and looking at 17 different risk factors to include pitch speeds, pitch counts, types of throwing, so breaking balls for instance, and then looking at elbows, looking at shoulders, looking at height, weight, kinematics, and not– 17 different factors.

Scott Gilbert – What did you find? This is great stuff.

Dr. Aman Dhawan – Yeah. So it was really very interesting. So, you know, some of the traditional things that you think of, obviously throwing year around, throwing high velocity pitches repeatedly, weight, height, these are all issues that you would expect to cause issues with throwing and indeed they do. Some of the more surprising findings of the study is that actually breaking balls may be protective of your shoulder and elbow. And it’s not– I don’t want to encourage players to just start going out throwing breaking balls, you still have to throw them correctly. But the idea is, if you look at even the biomechanics of breaking balls and its effect on elbow ligaments, it actually is less stressful throwing correctly than a fastball.

Scott Gilbert – Yup. Fastball is– Well, we could go on for minutes and I think we’ve hit a– going down a rabbit hole here. We could both talk about it for quite a while. But I mean it’s true. The fastball has been found to be a little more evil than the curveball.

Dr. Aman Dhawan – Absolutely. And so, in a way breaking balls again if thrown correctly really can be in some ways protective for the young elbow because again it decreases some of the stress on the elbow while they’re still throwing. So, again, you’re moving up in the pitch counts but you’re throwing pitches that are perhaps less stressful on your shoulder and elbow than a fastball.

Scott Gilbert – You’re watching Ask Us Anything About Shoulder Pain from Penn State Health. We’ve had some great questions. We encourage you to add any questions you may have in the comment field on this Facebook post. Again whether you’re watching us live here on Thursday or even after the fact, we’ll make sure we get you some answers here from Dr. Aman Dhawan. He’s an orthopedic surgeon here at Penn State Health. So we’ve talked about the causes, we’ve talked about treatments, let’s dial it back to prevention. Are there things that we tend to do to ourselves even just the course of every day that maybe we should do less of or maybe other things we should do more of to try to prevent shoulder pain?

Dr. Aman Dhawan – Absolutely. So, you know, I mean overuse and repetitive injuries, has become a hot topic particularly in youth athletes, but really it’s true for any of us, you know. So, you know, one thing I tell young athletes and older athletes and active people in general is, you know, modify your routine. So, you know, if you’re a young athlete and you enjoy playing soccer or baseball or hockey or what have you, you should try to play multiple sports. It decreases the amount of singular stress on a singular body part over time. And obviously that decreases overuse injuries. In older adults, you’ll find people doing the same workout routine year in, year out, year in, you’re out. Cross train, you use different types of training routines, use different types of machines. Don’t just use free weights. Use ropes, use Nautilus or Cybex type. So there’s a lot of different things that you can do in terms of staying fit, keeping muscular strength, keeping muscular bulk without having to do the same routine over and over. And that’s whether you’re a youth athlete or you’re an adult. So overuse injuries I think are a big reason why we see a lot of these things and variety is key.

Scott Gilbert – Yeah. So working out, you think you’re doing the good things for your body, it might actually be doing some bad stuff there.

Dr. Aman Dhawan – Absolutely. You see, you know, for instance, you know, if you do– like to do military press, great exercise for your deltoids for instance, your anterior middle deltoids, great exercise. But if you only do military press and you’re doing that several times a week with every time you work out or maybe every other time you work out, you’re going to create issues with your rotator cuff because you are putting a significant amount of strain on them. Now, if you do military press once a week or let’s say, you know, once every couple weeks but also provide some variety to your deltoids to include flies or even exercises that work out more a general area like push muscles, chest anterior deltoids triceps, you’re going to get a lot of that benefit of deltoid workout but without specifically singling out the deltoid in or causing shoulder injuries.

Scott Gilbert – We have a question from Lee now. Lee is asking, if there’s a certain movement or a pain location where you know you have rotator cuff damage? I mean, are there certain indications that a person can figure out before visiting the doctor that, yeah, this might be a rotator cuff issue?

Dr. Aman Dhawan – Yeah, absolutely. Now, again, there’s a lot of overlap on the shoulders. So there’s not one kind of hallmark pain location that, you know, if you’ve got it, you’ve got a rotator cuff problem. But in general, rotator cuff issues are problematic on the side of the shoulder. And they’ll often be described as going down the side of the shoulder almost to the elbow. People will almost describe an arm problem versus a shoulder problem. I’ve had patients who, you know, I’m seeing for the shoulder. Indeed it was a rotator cuff but they could have sworn they had an issue in their arm, all right, because they’ll feel it come down the arm. That’s because that anatomy of the subacromial bursa. So, typically, rotator cuff pain occurs down the side of the shoulder. It doesn’t have to in isolation but that’s certainly the most common location of that, as well as pain with overhead activities and pain at night. So those are kind of the three things that will really tip me off to, this could be a rotator cuff problem. They’re having pain down the side of the shoulder. They’re having pain at night sometimes which wakes them up from sleep, and pain with overhead activities.

Scott Gilbert – Lee’s question reminds me of a broader one, and that is if someone’s experiencing shoulder pain, obviously they can try to ice it, they can try the Ibuprofen, really good suggestions. At what point do you recommend that they see a physician about the pain?

Dr. Aman Dhawan – So certainly if the symptoms are getting worse despite those simple activities, icing, activity modification, anti-inflammatories and your symptoms are getting worse, that’s a good reason to see a physician. That’s not something that should be happening. Also if the pain has been going for a while, so more than six weeks, you know, really you’re doing those things and it’s not changing, that’s a good reason to see a physician. If you have loss of range of motion or major loss of strength, so you find that you can’t get your shoulder above your head anymore, you can’t do some things that you could do a month ago, that’s very concerning. And then if you have seen loss of strength is an issue as well, and so, all of those are problematic. In younger patients sometimes especially after a major injury, they’ll describe clicking and popping in their shoulder such that it feels like their shoulder is coming in and out of place. That’s also a problem. That often indicates a labral tear and that’s something that you should see a physician for.

Scott Gilbert – OK. And we will put contact information for Penn State Bone and Joint Institute in the comment field below this Facebook post, because after hearing– watching this video, you may want more information about the services here. You may wonder, you know, maybe I should see a physician. So we’ll make sure we put that information there, or you can call the care line as well which you can find at hmc.pennstatehealth.org. You know, I’m wondering if there’s ever a time when shoulder pain could be a sign of other medical conditions, I mean cancer or something else, I mean something that’s not related directly to a deterioration of the bone.

Dr. Aman Dhawan – Sure. Yes. And, you know, particularly in patients who had oncologic process like cancer, you know, when they get pain anywhere, they get nervous about that. And so, signs that this is something more serious. And again, by no means does it mean it is this. What it means, it probably should get checked out are things like night sweats, all right, fevers, chills, issues of radiating pain that are going down your arm or in other areas of your body, going into your chest or into your back, weight loss. These are all issues that, you know, this probably should get checked out. It might not be cancer. It might be a nerve impingement. It might be a number of different things. But certainly, those are all more concerning than just simple shoulder pain, weight loss, night sweats, fevers, chills, radiating type symptoms particularly burning or electrical type feelings, radiation into the chest or the back. These are things you probably want to get this checked out sooner rather than later.

Scott Gilbert – I have a question now from Lee. He’s asking, is the pain in front of the shoulder– I’m going to say it again, is pain in the front of the shoulder a symptom of something serious? So, I guess he’s talking about if we can get our model up, we’re talking about a pain up toward the front part right up in here, maybe even including the clavicle.

Dr. Aman Dhawan – Yeah. So, you know, as you can see, a lot of different anatomy here in the front of the shoulder. So the short answer is no. Having pain in the front of the shoulder is a very, very common– I’m going to take this off.

Scott Gilbert – Sure.

Dr. Aman Dhawan – Just because it’s going to keep falling off. But the pain in the front of shoulder is extremely common complaint and does not necessarily mean something serious. Often, it can be coming from things like long head biceps pain. So you see part of this bicep standing. You see that signified here by that white there, that white band. That’s often a cause of anterior shoulder pain. Other causes of anterior shoulder pain can be problems with the muscle I just took off, the subscapularis, or this joint here, the AC joint. So, as we would normally do, as long as you don’t have anything that would cause more concerns from the things I mentioned before, I would normally start with things like icing, activity modification, anti-inflammatories. And if it still bothers you after six weeks and you’re not really making a lot of progress or certainly if it starts getting worse, I would come see a physician.

Scott Gilbert – Good question here from Natalie [assumed spelling]. She’s asking, when does a patient need an MRI for shoulder pain?

Dr. Aman Dhawan – Yeah, great, great question. So we get that all the time. MRIs used to be a test that we would do very, very commonly. You know, you had shoulder pain. You got an MRI, right? So that was 15, 20 years ago. And that was just the common algorithm for that. And we’ve learned that, you know, most MRIs aren’t required. Most MRIs are done and don’t really provide any information that is going to change management. So this is why things have changed. It’s not that, you know, insurance companies and certainly medical systems are becoming more stingy, it’s just that that information doesn’t add anything more than that we can glean from a good physical exam, a good history taking and some X-rays. And so, we’ll usually start there and we use our clinical acumen to try to vet that out as far as what this could be and determine, is this something that needs an MRI. Issues that might lead you to then order an MRI, for instance, if the pain is continuing to increase or worsening, you’re having more disability, weakness, less range of motion despite the conservative management, despite having spent a few weeks in physical therapy, despite anti-inflammatories, despite time, those are reasons that what’s going on? Why is this happening? Maybe is this more than just a rotator cuff strain and might need some more treatment? And once we start thinking along that line, we’re starting to think along might this patient needs surgery? That’s a good reason to get an MRI.

Scott Gilbert – About how long does surgery last? And I realize that’s probably a trick question because it probably depends on the type of surgery, about five minutes to five hours. I don’t know. Is there a reasonable expectation and maybe give us an example?

Dr. Aman Dhawan – Yeah. So, you know, as you said, there’s so many different shoulder surgeries. So, you know, it depends on the shoulder surgery. I mean, really any time we do surgery, the expectation is that it’s durable. So, you know, there’s not a surgery I do that I don’t expect it to last years if not forever. Now, things like shoulder replacements for instance have somewhat a finite life. It is, you know, metal and plastic and it no longer has the ability to repair itself. So it can wear down its bearing surfaces like anything else like your tires. And so, you know, this is why often shoulder replacement docs will decrease the stress you put on it. Often, you know, they might limit you from heavy weightlifting for instance or repetitive overhead sports and that’s to decrease some of that wear, and that’s so that you get at least 15, 20 years out of that implant. Things like rotator cuff repairs often will last the rest of your life, all right? That doesn’t mean that they always will. Certainly, just because something is repaired doesn’t mean they it can’t re-tear. You know, the analogy I like to give is, you know, you suffer a bad car accident, you come in to the body shop, we make the body look all nice and shiny, doesn’t mean you can’t go back out and to the roads and get into a new accident. So, you know, these types of things happen again and it’s the same mechanism that occurred the first time absolutely can occur again. And that’s often why in surgery we try to reconcile that. For instance, if you have a spur underneath your acromion, we try to smooth that down. We remove that spur so that no longer is causing that attritional wear. So most surgeries we do, you can expect to be durable. They should be durable.

Scott Gilbert – And, you know, yet I think especially with surgeries of this nature where you’re going in there getting things done inside the joint, sometimes people put those off. In fact, they’re downright afraid of having it done. What can they expect in terms of recovery? Because I think that’s what a lot of people are worried about, not so much the procedure but the recovery. But, you know, what are things that you do as a practitioner to kind of help them through that process?

Dr. Aman Dhawan – Yeah, absolutely. So, you know, that’s that there’s a pink cars in humans, right? So you come into a body shop with your car, you need a new alternator, we put a new alternator and you drive off.

Scott Gilbert – Do you do that here?

Dr. Aman Dhawan – I actually have started to. No [laughs]. But, you know, you get your alternator replaced and you drive off the lot and you’re good to go. There’s no recovery rehab time. Human bodies require that. In fact, that may be just as important as a surgery itself. And so, you know, we take a very comprehensive approach I think here at Penn State Hershey Bone and Joint Institute where, you know, myself and other shoulder surgeons also focus on all the details to include right on the day of surgery pain management. We use a multi-modal pain management technique. We often will do regional blocks. We’ll use a number of different medicines. We try to avoid opioid pain medicines. And we start physical therapy early. So, most of us get patients into physical therapy within the first week after surgery. That helps decrease problems with stiffness, decreases pain, decreases swelling and gets patient feeling more normal. Certainly depending upon the surgery, you’re likely going to spend some time in a sling or an immobilizer of your shoulder. And to that end, you know, it’s good to make arrangements around your body, around your life in terms of work and in terms of home situation, ergonomic so that you can manage your environment with just one arm. But I think we do a very good job here not just cutting and running but providing really a comprehensive multi-modal approach to the care of not just the surgery itself but the perioperative and the recovery. So that, you know, until you are back doing the things you want to do, we’re with you every step of the way.

Scott Gilbert – Yeah. Care after the treatment is just as important as the care itself. So, Dr. Aman Dhawan, thank you so much for your time today, really great information here and really great questions. We appreciate those. Dr. Aman Dhawan is an orthopedic surgeon here at Penn State Health. You can find out how to get in touch with him and his colleagues here at Penn State Bone and Joint Institute in the information that we’ll be posting as a comment below this Facebook post here just to make sure that you know what those next steps are should you decide you need to take them. Thanks again to Dr. Dhawan and thank you for watching Ask Us Anything About Shoulder Pain from Penn State Health.

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