May 2022 - Johnny Nelson

Do I Have to Have Surgery for a Rotator Cuff Tear?

Arthroscopy, Rotator Cuff, Shoulder, Shoulder Surgery

Do I have to have surgery for my rotator cuff tear?

You may have recently been given a diagnosis of rotator cuff tear. Often, this can be given by a surgeon based on physical exam, a physical therapist based on your symptoms, or even based on imaging studies such as x-rays or MRI.

This diagnosis may lead to many questions for you.

Some patients think that just because rotator cuff tear is present, there is an immediate need for surgery. This is not actually true, as rotator cuff tears come in many different “flavors.” That is why it is very important to allow a shoulder expert like Dr. Johnny Nelson to examine your shoulder and discuss your unique situation with you.

It is important and helpful to look at the rotator cuff like a rope made out of a bunch of fibers. Some ropes are extremely new and extremely healthy, completely intact without any tearing or fraying. Other ropes may have some tearing and fraying of the fibers but overall remained intact. Then again other ropes may be completely torn, cut, or snapped and unable to be used.

The rotator cuff tendon is the same way.

Some patients have completely intact rotator cuff, with no tearing or fraying or even inflammation. Some patients have mild tearing of a few of the muscle and tendon fibers, while some patients have complete tears where the muscle is not connected to the bone.

We do have some evidence that smaller rotator cuff tears are less likely to become large tears, possibly scarring in place and healing. We also have evidence that large rotator cuff tears are more likely to get larger over time, and are less likely to be repairable the longer they are left without repair.

As a general rule, younger more active patients with more severe tears are more likely to be offered surgery and are more likely to respond well to that surgery. Patients with small tears are less likely to be offered surgery because there is evidence that these patients will often heal without surgery. However, even for small tears surgery is sometimes offered when treatments such as physical therapy, anti-inflammatory medications, and injections do not bring lasting relief of their pain and weakness.

If you have been told that you have a rotator cuff tear, or if you have been told that you need surgery on your shoulder, do not hesitate to make a visit to see Dr. Johnny Nelson to discuss your shoulder.

Sometimes knowing is half the battle!

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What is the Difference Between Standard and Reverse Shoulder Replacement?

Shoulder Arthritis, Shoulder Replacement, Shoulder Surgery

I have heard of shoulder replacement, but what is the difference between reverse and standard shoulder replacement?

The easiest way to understand this is to look at the normal arrangement of the human shoulder. It is basically a ball and socket joint, with the upper part of the arm bone as the ball, and the shoulder blade as the socket.

A standard shoulder replacement, also known as an “anatomic” shoulder replacement, simply re-creates this normal arrangement of the human shoulder. The ball at the top of the arm bone is refinished or replaced with a shiny metallic surface, and the socket in the shoulder blade is replaced by a special type of advanced plastic.

A “reverse” replacement simply “reverses” this arrangement. At the top of the arm bone, a special type of advanced plastic cup is placed, usually at the top of a stem that sits inside the arm bone. On the shoulder blade side, a shiny metallic ball is implanted into the shoulder blade, usually held in place by screws.

But why do some patients get reverse replacements and other patients get standard replacements?

There are 2 main reasons to use a reverse replacement.

The first reason is due to rotator cuff problems. Some patients with bad arthritis also have very large and long-term rotator cuff tears, and some may have complete absence of the rotator cuff altogether. The reverse replacement changes the arrangement of the shoulder joint and allows the patient to overcome this lack of rotator cuff and use the “meaty” muscle on the outside of the shoulder to lift and move their arm.

The second reason is due to the severity of the arthritis. Very advanced and long-term arthritis can cause wear and tear of the socket part of the joint that is so bad that doing a standard replacement places the patient at risk of complications such as instability and implant loosening. If this is the case, a reverse replacement may be the best option to avoid the risks of these complications.

If you are struggling with shoulder arthritis pain or rotator cuff problems, a visit with Dr. Johnny T. Nelson will shed some light on your unique situation. Using a combination of your history, physical examination, and review of available imaging, a treatment plan will be created that is right for you.

Call 919-872-5296 today to make your appointment!

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When Are Injections Used to Treat Shoulder Pain?

Injections, Shoulder, Shoulder Pain

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When Are Injections Used To Treat Shoulder Pain?

The answer to this question depends on the cause of your shoulder pain as well as the type of injection being considered.

There are two main types of injections used in and around the shoulder, these include steroid medications, which are the most common and PRP or “platelet rich plasma”.

Steroid is a type of medication that is used very frequently in medicine. Some forms of steroid are taken by mouth, some are used through an IV, and others are made to be injected into different locations, including into and around the shoulder joint. Steroids are actually naturally occurring, meaning that we normally have steroid in our body, but the type that is used for injections are slightly different and are made in a laboratory. Steroids work through the inflammation pathway, blocking several molecules that lead to inflammation, redness and pain. Therefore, they are very helpful for treating painful orthopedic conditions.

Dr. Johnny T. Nelson uses steroids for two main reasons in and around the shoulder.

The first reason is if the patient is in severe pain, sometimes this pain is so severe that the patient is not able to start or participate in physical therapy which may be the best treatment for that pain. Also, patients can have pain that is so severe that they cannot sleep, and they cannot work and provide for themselves. If that is the case, the decision is sometimes made to perform a steroid injection.

However in some patients, such as patients with large rotator cuff tears that may require surgery, Dr. Nelson sometimes avoids steroids because there is evidence that steroids impedes and prevents the healing that is necessary after shoulder surgery and rotator cuff repair surgery(1).

The second reason Dr. Nelson uses steroids is to identify the actual cause of your pain. Because there are so many structures in and around the shoulder that can cause pain, sometimes even with imaging, physical examination performed by your orthopedic surgeon, the actual cause of your pain may be unclear. A steroid injection around a structure may help to define or eliminate whether that structure is the cause of the pain. For example, Dr. Nelson often performs injections around the biceps tendon sheath under ultrasound, if the patient’s pain improves, it is very likely the biceps tendon is a cause of the pain.

Okay, what about platelet rich plasma?

Platelet rich plasma is a new technology that shows a lot of promise. Certain patients with certain problems around the shoulder can be candidates for platelet rich plasma therapy. These include patients with bad bursitis, inflammation, partial tearing of the rotator cuff, and even arthritis. Although the evidence for effectiveness of platelet rich plasma is limited because the technology is so new, it is a good nonsurgical treatment method to try in some situations.

Although platelet rich plasma is not usually covered by insurance, it is a simple process. It requires taking some of your own blood, spinning it down in a machine, and taking the portion of the blood that contains many special growth factors and other molecules and injecting it around the area that is painful and inflamed. This platelet rich plasma injection triggers an inflammatory response that after several weeks will quiet down, leaving the inflamed and painful area more quiet, healed, and less painful.

If you are having shoulder pain, call 919-872-5296 to schedule a visit with shoulder specialist Dr. Johnny Nelson. Before you see your primary care doctor, physical therapist, chiropractor, or other provider, it is important that you have a thorough history and physical examination by an orthopedic surgeon to establish the correct diagnosis!

References:
Puzzitiello RN, Patel BH, Nwachukwu BU, Allen AA, Forsythe B, Salzler MJ. Arthroscopy. 2020 May; 36(5):1468-1475. Epub 2019 Dec 17.

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How are Shoulder Pain and Neck Pain Related?

Shoulder Pain, Shoulder Surgeon

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Patients that have pain in the shoulder often will also have pain in their neck, and vice versa. Patients with neck pain may also have an experience pain in their shoulder.

This highlights the importance of beginning your treatment for musculoskeletal pain with an orthopedic surgeon who is an expert in evaluation and diagnosis of musculoskeletal problems and injuries.

So how exactly are neck pain and shoulder pain related?

The first way that they are related is by something called splinting. Patients that have pain originating in the shoulder joint, whether it is caused by inflammation, biceps tendon problems, arthritis, or rotator cuff conditions, will often perform splinting.

Splinting is an activity that we often perform without even knowing it.

Most people think of a splint as an object that we put on, but is also thing that we do. When we have pain in a certain joint, we can use the muscles that are attached in and around that joint to hold the joint still so that it hurts less. This is called splinting.

When the shoulder is painful, it is not uncommon to use the muscles at the base of the neck, the chest muscles, back muscles, and even muscles in your armpit to hold the shoulder still so that it does not hurt you. In the short-term this may make your shoulder feel better, however in the long-term it can cause harm because those muscles will eventually grow tired, experience spasm, and begin to cause pain themselves.

How else are shoulder and neck pain related?

Another way that neck and shoulder pain are related is that problems in the neck can often mimic shoulder pain. Because the nerves that come out of the neck send signals to and from the shoulder joint, problems such as pinching of those nerves in the neck can often be experienced by the patient as shoulder problems and shoulder pain rather than as nerve problems and nerve pain.

This is why a physical examination by a qualified orthopedic surgeon is of utmost importance.

Orthopedic surgeons are experts at distinguishing between pain that is truly originating in your shoulder and pain that is likely originating at the level of the neck. There are also experts at knowing what the next step is necessary, whether further imaging or surgery is necessary, or whether simple watchful waiting, physical therapy, chiropractic care, and anti-inflammatories is okay.

If you have shoulder pain, even if you have pain radiating into your neck, your back, or numbness and tingling traveling down your arm, a visit with an orthopedic shoulder and upper extremity specialist is a good first starting point to get answers and relief.

Call at 919-872-5296 to book an appointment with Dr. Johnny T. Nelson.

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Will Injections Fix my Shoulder, Elbow, or Hand Problem?

Hand Surgeon, Injections, Shoulder Pain, Tendonitis

Will injections fix my shoulder, elbow, or hand problem?

Steroid injections are commonly used in the treatment of shoulder, elbow and hand problems. As a result, there is some confusion about what these injections actually do for different conditions.

As a general rule, orthopedic surgeons such as Dr. Nelson use steroid injections for 3 main reasons:

1) To completely cure a condition, now and forever

2) To help relieve inflammation and pain that is unbearable for the patient, even if temporary

3) To help clarify exactly what condition the patient has and what structure is bothering them

What conditions can be completely cured with steroid injections?

Although we can never know and predict with 100% certainty that the steroid injection will cure a certain patient’s condition, we know that some conditions can be cured with a steroid injection. Problems that have high rates of cure with injection include tendinitis around the hand and wrist, including trigger finger. Problems with lower rates of cure include tennis and golfer’s elbow and shoulder biceps tendinitis, for example. Of course, the steroid injections are often administered along with recommendations for a period of rest, possibly bracing and icing, or physical therapy, which also may help the condition resolve.

Okay, so what conditions cannot be cured with steroid injections?

One of the most common reasons to perform injections around joints is arthritis, or wear and tear of the joint surface. It is important to understand that the steroid injection does not fix or reverse the arthritis. Arthritis is always there, and in fact tends to progress with time, no matter what you do. The main reason to perform injections for problems like wrist, hand, or shoulder arthritis is to “kick the can down the road,” temporarily reducing pain so that the patient can remain active, participate in physical therapy, and avoid resorting to surgical intervention.

Nerve problems also usually cannot be cured with steroid injections. For example, carpal tunnel syndrome is very common, and injections are often used to help reduce patient’s symptoms, especially if the carpal tunnel syndrome is due to a new or recent activity and the patient is not able to undergo a carpal tunnel release. But usually the carpal tunnel symptoms will usually return after a time.

So how can injections help clarify the cause of pain?

Sometimes even the best orthopedic surgeon has difficulty knowing with 100% certainty what structure is the cause of pain, or what the correct diagnosis is. Sometimes a good option is to perform an injection to clarify if a certain structure is the cause of pain. If an injection of steroid around the structure make the pain go away, even for a short time, this tells the patient and surgeon the injected structure is likely the cause. We also know that patients who have relief of their carpal tunnel symptoms, even temporarily, after injections are very likely to respond favorably to a carpal tunnel release with permanent relief of their symptoms.

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“Aren’t I Too Old For Shoulder Replacement?”

Shoulder, Shoulder Arthritis, Shoulder Pain, Shoulder Replacement, Shoulder Surgery

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“Aren’t I too old for a shoulder replacement?”

This is a common way of thinking amongst older patients who struggle with chronic shoulder pain due to to things like arthritis and long-term rotator cuff tears.

But while it is very common, this way of thinking is actually based on several misconceptions about shoulder replacement surgery and the impact it can have on one’s quality of life.

In fact, shoulder replacement surgeons such as Dr. Johnny Nelson believe that the overall benefits of shoulder replacement surgery are higher in older patients compared to younger patients.

Some of this is because any joint replacement, including shoulder replacements, have a limited life span. Even if perfectly placed, shoulder replacement implants over time experience the same wearing tear that our normal joints experience over our life times. Because of this, shoulder surgeons are less likely to recommend shoulder replacement on very young patients, even if the arthritis and pain is very severe. Younger patients are more likely to wear out their shoulder replacements and require a second procedure.

Older patients are much less likely to have this problem. This is because the needs and activities of older patients are very different from those of younger patients. Older patients are much more likely to use their shoulders for simple, less strenuous activities: hygiene, dressing, cooking, etc. They are less likely to need their shoulders for heavy lifting, pushing, pulling and repetitive overhead motions. Therefore they are actually much better candidates for shoulder replacement surgery than younger patients because they are less likely to have complications with their implants.

Another reason why older patients are better candidates for shoulder replacement surgery is that the pain relieving benefits of shoulder replacement can be life-changing for them. While younger patients with chronic shoulder pain certainly could benefit from shoulder replacement, they are less likely to lose their independence and rely on friends, family, and other loved ones for help. Many older patients who struggle with chronic shoulder pain find it very difficult to stay independent, take care of themselves and maintain their living environments. Those who do not receive proper treatment for their shoulder pain may find themselves increasingly dependent on others, even having to sell their homes and move into assisted living facilities or in with family. Many older patients who undergo shoulder replacement surgery are able to maintain or even improve their level of independence and quality of life due to the improved ability to use their once painful arm.

Are you struggling with chronic shoulder pain that is interfering your independence and quality of life? Schedule a visit with Dr. Johnny Nelson to see if shoulder replacement surgery could be a life-changing option for you!

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