Marc Darrow, MD

As your shoulder pain has worsened, you have started to more closely examine surgery, specifically shoulder replacement, as a means to help you with your symptoms. For most people, when symptoms progress to the point that they are in severe pain, have a significant loss of range of motion in their arms, they are not being able to sleep at night because of the pain and they have already had long bouts of physical therapy, cortisone injections and live on painkillers and anti-inflammatory pills is there anything else left for them to consider? The answer is possibly. This article will explore why treatments may have failed you, the possibilities of when shoulder replacement can be avoided or delayed, and the realistic assessment that shoulder replacement may be the only thing that can help you at this time.

Many people contact our office after conservative treatments have failed and shoulder replacement surgery is being strongly considered. What these people who come into our office are looking for is a treatment and healing program that they can see as being a realistic option.

An ultrasound examination and treatment guided program

A June 2021 paper in the Journal of ultrasonography (1) describes the use of ultrasound technology in terms of diagnosis and treatment guidance. We use this technology in our office. Here is the research:

“Ultrasound is a fast, accessible, reliable, and radiation-free imaging modality routinely used to assess the soft tissues around the shoulder. It enables to identify a wide range of pathological conditions. Furthermore, most ultrasound-guided musculoskeletal interventional procedures around the shoulder produce better results in terms of accuracy and clinical efficacy than those performed in a blinded fashion.

Indeed, intra-articular and peri-articular interventional procedures can be easily performed under continuous ultrasound monitoring to ensure the correct position of the needle and to deliver the medication to a specific target.”

What the researchers noted is that ultrasound technology can help the doctor “treat acromioclavicular osteoarthritis as well as glenohumeral joint osteoarthritis and adhesive capsulitis.” It can also be used to guide the doctor in aspirating the shoulder as in treating “subacromial-subdeltoid bursitis, either presenting as a primary inflammatory condition or secondary to rotator cuff disorders, can be easily approached using ultrasound guidance to aspirate synovial effusion (fluid) and to inject medications.”

Conservative care and shoulder replacement

As medical research is quick to point out, there is no cure for osteoarthritis. What doctors and patients hope for in non-surgical or conservative treatment options is to reduce or eliminate pain and improve function enough to consider the treatment a success.

Many people with shoulder pain however, now being recommended to shoulder replacement have already tried many of the treatments that unfortunately did not slow the progress of their osteoarthritis or help enough with the pain. This is why the replacement surgery is being recommended to them.

Typical conservative treatments included:

  • Rest
  • Activity modification
  • Physical therapy
  • Oral and topical anti-inflammatory medications
  • Massage therapy
  • Electrostimulation
  • Cortisone injections
  • Hyaluronic acid injections

When all these treatments fail, people may seek still more alternative and “controversial treatments” for their shoulder pain. These treatments will be discussed later in this article.

Cortisone injections for glenohumeral osteoarthritis

Cortisone injections are of course controversial. Decades of research have shown that these injections, while providing temporary pain relief, can cause long-term problems. Among them is the destruction of the very shoulder cartilage that the patients are hoping to preserve to prevent them from going bone-on-bone and needing a shoulder replacement.

In a study from May 2021, doctors assessed the effectiveness of  cortisone injections for glenohumeral osteoarthritis because “the amount and longevity of pain relief provided by a single cortisone injection are unclear. Additionally, it remains uncertain how the severity of radiographic glenohumeral osteoarthritis and patient-reported function and pain levels impact the efficacy of an injection.”

The researchers concluded that one injection was probably the best recommendation as with the injection worked or it did not and if it did not work there would be no need to try it again. However, they write: “patients with more severe shoulder dysfunction based on the Oxford Shoulder Score (a standard pain score) did experience statistically significantly greater symptomatic relief than patients with milder dysfunction. Additionally, following a single injection, patients in this cohort experienced statistically and clinically relevant improvements in shoulder function and pain up to 4 months after injection.” Pain relief was provided to some for up to four months after the single injection.

When shoulder replacement surgery seems to be the only option

Shoulder replacement surgery can be a very effective procedure for many people. But it will not be successful or recommended for some with advanced shoulder degenerative disease. If your rotator cuff is significantly damaged Total Shoulder replacement may not be recommended. Instead your surgeon may recommend a Reverse Should Replacement.

Reverse Shoulder Replacement

In this surgery the doctors reverse natural anatomy. The ball of the shoulder is put into the socket and the socket of the shoulder is put where the ball was. That is why it is called reverse shoulder replacement.

Pain after shoulder replacement

While complication rate is considered low for many patients, some patients do have long-term pain after their shoulder replacement. How does this happen?

In one study significant pain following a shoulder replacement was still seen as a successful surgery. How?

In a paper published in the Journal of shoulder and elbow surgery, researchers assessed a scoring system to demonstrate what the minimum pain relief results would need to be to call a shoulder replacement surgery a success. Using the visual analog score (the image below represents the VAS visual analog score system. 0 for no pain – 10 unbearable pain)

In 326 patients who had either a total shoulder replacement, a primary reverse shoulder replacement, or hemiarthroplasty (replacing the ball with a metal ball), in averaging out the patient response outcomes, the researchers found that patients treated with a shoulder replacement require a 1.4-point improvement in the visual analogue pain score (1)

If you went into the surgery with a 9 score on the above scale and you came out of surgery with a 7.6 rating, severe pain, your surgery would be a success because it met the criteria a minimal clinically important difference (success). Any pain relief is welcome, but how many people would have the surgery for a 10% improvement?

1 Tortora S, Messina C, Gitto S, Chianca V, Serpi F, Gambino A, Pedone L, Carrafiello G, Sconfienza LM, Albano D. Ultrasound-guided musculoskeletal interventional procedures around the shoulder. Journal of Ultrasonography. 2021 Jun 7;21(85):e162.

2 Tashjian RZ, Hung M, Keener JD, Bowen RC, McAllister J, Chen W, Ebersole G, Granger EK, Chamberlain AM. Determining the minimal clinically important difference for the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog scale (VAS) measuring pain after shoulder arthroplasty. Journal of shoulder and elbow surgery. 2017 Jan 1;26(1):144-8.

 

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