Dr. Peterson Shares Shoulder Suggestions

Posted: September 1, 2016

NorthBay Healthcare orthopedic surgeon Robert Peterson, M.D. got shoulder-to-shoulder with our followers on Facebook Aug. 18, answering questions for more than a half an hour during #OurDocTalk.

More than a half dozen questions were posted for the live text chat focused on shoulder injury prevention and treatment and Dr. Peterson spent time explaining the function and structure of the shoulder and how injuries can affect them.

“It is not uncommon for shoulder injuries and/or surgeries to be followed by permanent changes in the function of the shoulder,” he explained in one post.

When another post asked about pain above the bicep, Dr. Peterson took the time to explain tendonitis and the structure of tendons in the bicep muscle and explained common care for injuries.

“As with most cases of tendon inflammation, initially conservative care is advisable,” he noted, adding that icing the area and taking anti-inflammatory medications might help.

Another topic of several questions involved aftereffects of rotator cuff surgery.

“Unfortunately, it is not uncommon to develop what amounts to a rotator cuff tendonitis during rehabilitation,” Dr. Peterson explained. “And depending on the size and circumstances of the repair, rehabilitation in some cases can last up to a year.”

#OurDocTalk, is a series of live Facebook chats designed to connect NorthBay doctors with the community to answer questions on a variety of health issues. Interested followers who visit NorthBay’s Facebook page (Facebook.com/NorthBayHealthcare) post their questions and comments and the doctor replies at a scheduled time and date.

Here is a transcript of Dr. Peterson’s chat:

Q.: Comment: after 6 months of a rotator cuff shoulder surgery can you develop a pain around the cuff or have the arm fall asleep more?

Dr. Peterson: Unfortunately, it is not uncommon to develop what amounts to a rotator cuff tendinitis during rehabilitation. And depending on the size and circumstances of the repair, rehabilitation in some cases can last up to a year. Discomfort tends to come and go during the recovery period. Sometimes your surgeon may recommend additional techniques for pain relief including specific stretches or exercises, ice or heat with therapy, medications, even injections and sometimes brief rest periods. The course of rehabilitation is highly variable. As to the numbness, this is often a secondary feature of shoulder injuries, both before and after surgery and as a rule as the inflammation and scar tissue related to surgery get better, the symptoms of numbness tend to go away.

Q.: I know someone who fell really bad on their right shoulder 10 years ago and it has never worked the same. When doing things, they can't do it very long because of pain and weakness. They can't use it like they used to. They don't have the mobility they had before the injury. There is a stretch they do but they have to stop at a certain point when it's starts causing pain in their neck. What is going on?

Dr. Peterson: While it is difficult to give an accurate assessment, because there are multiple variables, it is not uncommon for shoulder injuries and/or surgeries to be followed by permanent changes in the function of the shoulder. Possible causes could include previous fractures or patterns of instability, scar tissue or post-injury deformities that can in some cases be correctable. This would be a case that would likely benefit from an updated examination and full evaluation, to try to determine the mechanisms of the initial injury and the mechanical changes that have occurred over time. The ability of modern shoulder surgery to correct even chronic changes has advanced significantly over the last 20 years but more detail would be necessary to provide a definitive answer.

Q.: When a person has on and off pain in their should around the socket area for weeks, what could cause this?

Dr. Peterson: There is a wide variety of possibilities. Primary factors would include the age of the patient, whether or not there has been a traumatic episode, the presence of provocative motions or activities, and a host of other factors that may give some clue to the likely diagnosis. A detailed history and physical examination will, in most cases, point to the likely cause or source of dysfunction even before the use of other modalities such as X-rays and MRIs. There are, surprisingly, a wide variety of causes for shoulder pain. Depending on the circumstances, rotator cuff tendinitis and subacromial bursitis are among the most common and typically respond to conservative care including activity modification, a period of limited use, and the occasional addition of anti-inflammatory medications or the local use of ice or cold therapy followed by gradual return to activity with light mobility and strengthening exercises.

Q.: I know someone that had two shoulder surgeries in 6 months 16 years ago. Since was diagnosed with Chronic pain syndrome, there are times they cannot barely comb their own hair. The left arm has swelling & around the neck, hurts in the center of the back nerve pain in the left side of the cheek?

Dr. Peterson: While there are many possibilities regarding the two shoulder surgeries, the overall description here would seem to fit a diagnosis of complex regional pain syndrome (CRPS). This syndrome describes abnormal function of the nerve supply to a specific area. In this case, the upper extremity and the neck or cervical spine. While CRPS can be related to injuries or surgery, it can also be idiopathic or without specific cause. As an orthopedic surgeon, I will often refer patients with this problem to colleagues who are pain specialists or neurologists for treatment of what can be a difficult and in some cases, poorly understood syndrome. Multiple treatment options have been described as this is often a very complicated issue. Often a consultation with a pain specialist is advisable.

Q.: Best ortho Doc. Ever!!

Dr. Peterson: Thanks for the kind words, Margaret!

Q.:Hypothetically... A person wakes up with sore shoulder (denies trauma) and unable to move it up above their head, comb hair, or put a bra on for nearly a week. Does have lateral abduction without pain or spasm. After 1.5 weeks of Motrin, rest, and ice shoulder is mostly back to normal. Fast forward 8-10 weeks and full ROM is present except a twinge when reaching up like to stretch, or getting something off the top shelf. There is also point tenderness on anterior portion of arm below shoulder joint but just above bicep, and it feels like there would be damage done if a person was to try and work out with weights or push-ups. Thoughts??

Dr. Peterson: Given the specific localization of the tenderness, the first consideration would be a tendinitis of the long head of biceps. Biceps has two tendons proximally or near the shoulder. The long head, travels through a small groove in the front of the humerus and continues on into the joint. It is, therefore, often an area exposed to high stresses and repetitive use. Everything from mild tendinitis to rupture of this tendon can be seen in the clinic. As with most cases of tendon inflammation, initially conservative care is advisable, ice locally, anti-inflammatory medication, or an active rest period, meaning that we do not want to completely discontinue shoulder activity, which would promote stiffness or weakness but rather would prefer to maintain activities that can be performed without significant pain using other muscles and trying to maintain basic motion. The early pain can prohibit even simple motions when inflammation is more severe. It sounds like they have done a good job of restoring and maintaining motion. Once pain has subsided, a gradual return to biceps function can be encouraged. This often requires a decrease in exercise load such as lower weights or less repetitive use and a gradual return to previous level of function. It is a good sign that motion has returned. Gradual return of tendon function should follow.
Response: Thank you Dr. Robert Peterson and NorthBay Healthcare for the valuable information. I appreciate you.

Q.: Can screws from a humerous fracture cause pain in the shoulder? I know of a situation where after surgery and therapy the patient had full ROM and no pain after about 9 months, but developed new pain at around 1.5 years post surgery. There is pain with and without movement. No changes in the ROMi

Dr. Peterson: While most implants or hardware are well tolerated and designed to be present permanently, there are certainly cases where implants can create local tissue irritation usually mechanically but rarely a reaction to implant materials that can result in symptoms. These symptoms can begin in many cases unpredictably, even after a considerable amount of time has passed since the surgery. Important details would include location of the screws, the type of fixation and which tissues are included in the injury. It is not uncommon to perform surgery to remove hardware in a timeframes even years down the line. There are some occasions where local hardware symptoms may be treated with local pain relief products, or in some case, local injection.

Q.: If someone has been going through some sharp pain in their shoulder, how can they tell if their rotator cuff has a tear?

Dr. Peterson: Rotator cuff tears in some cases exhibit classic symptoms including rotator cuff weakness or pain with specific provocative tests. However, the symptoms also overlap to a great extent with local tendinitis or bursitis. Therefore, in many cases, a careful history and physical examination may be enhanced by the information provided by X-rays or MRIs, which are more effective at evaluating soft tissue. It can be difficult to definitively diagnose a rotator cuff tear without imaging studies in some cases.

Q.: I know someone whose left shoulder was injured doing standing wing files over 3 years ago. As they were lifting, they had a painful snapping sensation which they say hurt all the way down their shoulder blade and up their left side of their neck. It took almost a week to start feeling better. Ever since then they have been very prone to the same injury but now almost anything can trigger it, even once when all they did was look down. They have had no kind of physical or scans, just some physical therapy that didn't seem to help. They still feel prone to the injury and can feel their shoulder is always a little sensitive. Visits to the gym in hopes to strengthen the muscle don’t seem to be making much difference and they feel like they are losing. Should they just go back to physical therapy ? Find a new doctor? Any suggestions?

Dr. Peterson: The description of the injury suggests musculotendinous injury of the shoulder girdle which can describe the group of muscles that aids in mobility and stabilization of the scapula, or shoulder blade. These muscles attach the shoulder blade predominately to the spine. The most obvious example would be trapezius, the large muscle you can feel connecting the shoulders to the neck. This is one of the family of muscles that help stabilize the shoulder blade and are commonly injured with high stress activity such as weight lifting, also commonly involved in sudden tramatic injuries, sometimes described as whiplash injuries. Another possibility is involvement of nerves at the level of the neck, as this can give pain that radiates distal to the neck, or away from the neck, and can present in many different patterns. Dysfunction or muscular imbalance involving positioning of the shoulder blade is also a possibility. In short, this is a condition for which I would recommend a careful evaluation of the local musculature as well as the neck and shoulder to separate out potential causes and to make a focused treatment plan possible.

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