BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP
Programme No. 3 - Shoulders
RADIO 4
THURSDAY 06/12/07 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
PROF. ANGUS WALLACE
PRODUCER:
BETH EASTWOOD
NOT CHECKED AS BROADCAST
MYERS
Hello. Now if your shoulders ache after a day at the office or even worse if you've been out shopping it may well be that you're suffering from either tension or strain in the neck and upper back. But our programme today is concerned with problems arising from the shoulder joint itself. When symptoms of pain and restricted movement are more likely to be felt in the upper arm, maybe even running down to the wrist.
Shoulder pain is often given a diagnosis of frozen shoulder, which is, itself, a well known and a treatable condition but it could be a shoulder impingement, it could be arthritis. If you'd like to know the difference and what difference that makes to treatment then you've come to the right place. I'm joined today in the Check Up studio by orthopaedic surgeon and world authority on shoulders Professor Angus Wallace. And plenty of you have phoned in with your problems. We'll start with Derek who's in Lincoln, got a painful shoulder, in particular - what kind of pain, what sort of restriction Derek?
DEREK
Hi, good afternoon. Yeah it's a dull pain that comes after prolonged driving with my elbow on the rest of the door and I also play sport - some golf - and I feel that there's a sharp pain running down into my hand - when I'm playing - swinging hitting the shot it's like in the hand and the shoulder, just a dull annoying pain.
MYERS
That sounds very clear indeed, let's put you over to the expert, Professor Wallace what would you say if Derek turned up in your clinic?
WALLACE
Well firstly Derek it's important for me to know whether you have had an injury to that shoulder in the past, have you ever fallen and injured the shoulder or is this ...?
DEREK
I have, yeah, you know I did - I was out biking with the family once and injured the shoulder. But what's annoying is when - I mean I did a bit of training in the summer when I did some press ups and chest presses, I tried it the other day and the shoulder just collapsed under the pressure.
WALLACE
The story suggests that you might have torn the ligaments inside the shoulder and the shoulder might be partly dislocating. That occurs after an injury, a fall from a bike's enough to do it, it settles down for a while and then starts to give you problems later on, particularly when you try to use the arm above shoulder level. So if you're getting pain above shoulder level when you're reaching up to a shelf and the shoulder feels as if it's just not right what you should focus on first is strengthening exercises, which you've already done, you might manage to improve your exercises by using a ball worker, which you can purchase in a sports shop, build up the muscles around the shoulder and if that doesn't improve you then you need investigation to see whether you've actually got a partly dislocated - partially dislocating shoulder.
MYERS
So are you saying this is where the shoulder sort of drops out - the ball from the socket - and that can happen - I mean obviously not totally as you're saying?
WALLACE
Well the classic injury occurs in rugby, when you see the rugby player and his shoulder comes out of joint and it gets deformed. But many people have a minor degree of that injury where it comes out for a second and jumps back in and you don't actually know when that's happened. And then you go on with chronic symptoms after that.
MYERS
And strengthening can kind of hold it better?
WALLACE
The muscles around the shoulder, when they get stronger, hold the ball on the socket and tend to stop it coming out of the socket.
MYERS
Okay, well I hope that's been helpful Derek, stay listening because of course there'll be more advice coming up. We go to Yvonne, who's in West Yorkshire, worried about her shoulder. What are your symptoms Yvonne?
YVONNE
Good afternoon. My symptoms are a pain in the front of the shoulder and when I lift my arm. It started about eight months ago after doing some garden work and I thought that the pain would go in time but it's still here. I don't know if I should go see a doctor or maybe it will go in time, I don't know if I've sprained it or ...?
MYERS
Well make a start by talking to a doctor, in fact an orthopaedic surgeon. What would you say to Yvonne?
WALLACE
Well Yvonne firstly, at the moment, can you lift your arm all the way up to the top, so that it points straight up at the sky?
YVONNE
Yes I can.
WALLACE
You can. That means that you don't have an early frozen shoulder, which is what I thought initially, and it's more likely to be a mild form of what we call impingement. Now impingement means that the tendon inside the shoulder, called the supraspinatus tendon, is squeezed between the ball of the shoulder joint and another bone and that squeezing causes pain. And it sounds as if you're intermittently getting that. Now you can treat yourself with some anti-inflammatories, which may well settle it quickly or some strengthening exercises from a physiotherapist.
YVONNE
I've tried inflammatory tablets, I took them for about three weeks, but the pain's still here.
MYERS
And isn't that always the problem with just taking painkillers, for a start people don't really like to be on painkillers for a length of time, it's not really actually doing anything about the underlying problem is it Angus?
WALLACE
I'm a great believer in a short blast of anti-inflammatory, if it doesn't work then you've actually got to think about something else, you shouldn't be taking anti-inflammatories long term. And so at this stage, having had anti-inflammatories, had physiotherapy, I would be recommending a doctor sees you with a view to giving you a local anaesthetic and steroid injection. That's going to have a 50% chance of curing you, just with one injection.
MYERS
How would it cure you with just one injection - that sounds like a miracle?
WALLACE
The shoulder is inflamed, that's what it sounds like, and when it gets inflamed and the tendon is being nipped the tendon swells. If you can reduce that swelling then there's more space for the tendon to move in and that will allow the tendon to settle by itself. The difficulty is that you can get inflammation and a tear of the tendon and if there is a tear often the symptoms don't settle, even with an injection. And then we've got to think about surgery.
MYERS
Okay so a step at a time. Let's go to another caller, if I may, from Hove in Sussex, Philip Palmer, I think, is on the line, I think also concerned - though perhaps you've already had a diagnosis - but wondering if impingement might explain your symptoms. Can you just tell us what they are Philip?
PALMER
Yeah I've had it for about a year now and got it through throwing the ball for the dog, rather foolishly.
MYERS
It's always the simple things isn't it that you wish you hadn't done.
PALMER
Yes, yes. And I have sort of quite good movement in my shoulder in general but if I lift it sort of directly to the side and try to go straight up I can only get it sort of just under level with my shoulder and I now can't put my - I can't soap my back in the shower...
WALLACE
Right. But when you do that Philip do you get quite severe pain, is that ...?
PALMER
Yes.
WALLACE
Yeah okay. Now if you actually lift the arm beyond the shoulder level can you get above the pain?
PALMER
If I lift it ...
MYERS
You're trying now aren't you.
PALMER
Yeah I am ...
MYERS
I can see you.
PALMER
If I lift it at the front I can go right up to the top, but if I go directly to the side I can just about get it - yes I can ...
WALLACE
You can get above it. This is a classical painful arc that doctors know about. Which means that you have a mid arc - painful arc - you've got no pain at the bottom, you've got pain halfway up and you can get above the pain. Now that is the classic sign of impingement. So you have impingement and that impingement means that the tendon is being squeezed by the ball of the shoulder joint and squeezing towards a bone above it called the acromion. It's sometimes called tendonitis, same condition, it just happens to have a different name. And it sounds to me as if having had it for a year you really ought to be getting some treatment from your GP. You've had some physiotherapy?
PALMER
Yeah I've had physiotherapy, the physiotherapy - physiotherapist has given up on me, basically she said she didn't want to take my money anymore because it wasn't getting any better.
WALLACE
Well good for the physiotherapist, I'm a great believer in physiotherapists treating you for three, four, five sessions but if you're not getting better there's really no point in continuing. And I get very annoyed when I see patients who have spent a lot of money going to see physiotherapists over a long period and been treated 20 times. So your physio's done the right thing. You need to go back to your GP and you need to ask your GP if he is able to give you an injection and if he's not to pass you on to somebody who can.
PALMER
Yeah, yes, you think an injection would be worthwhile in this case?
WALLACE
Definitely because I believe for the sort of complaint that you've got we're talking about a 50% cure rate, one injection and you've got a 50% chance that that will settle it and you won't need anything else done.
MYERS
Hope that's useful. Just a question about - I think Philip said that he threw a ball to the dog and that brought it on - what are the movements that perhaps could bring that on, I mean would he be right in saying that or did he notice it after he happened to have thrown the ball?
WALLACE
Ahh what has probably happened is that in throwing the ball the tendon was either stretched or squeezed and then became painful afterwards. It then became swollen and then the condition became chronic.
MYERS
Is there something we could be doing ourselves then to look after our shoulders a little bit better because I'm hearing a lot of people with a lot of pain and I'm thinking well what can you do that's a little bit protective of the shoulder joint in that case?
WALLACE
Gentle strengthening exercises, what we call rotator cuff exercises, but pushing the arm out from the side with the elbow straight, bending the elbow and pushing the wrist out to the side against a door or a doorframe. That gives you a strengthening exercise that you can do. You can get, what we call, exercise elastic, it's commercially called Cliniband which is like a big elastic band and you work with that to pull and push, in order to strengthen the muscles. Or if you want to go to the super duper version, that's the ball worker which it does look like a giant elastic band.
MYERS
I wish everyone could see you because of course you're making the movements that you're talking about but we'll have some more detail, I hope, on our website at the end of the programme so that people know where they can get perhaps more details about some of these exercise routines but thanks for that. Let's not keep Kitty waiting any longer, she's in Romford and wants to talk to us. Kitty, it's your turn.
KITTY
Oh hello. I have been listening, good afternoon. Like the previous callers it seems I've got a bit of each of those. I can't lift my left arm right up, I can't put my arm back to tuck my vest into the back of my jeans. I have to lift my bad arm up with my good arm, so that I can wash properly and put deodorant on.
MYERS
And have you had any treatment for this.
WALLACE
Oh Kitty, Kitty that is a beautiful description, I can tell what you've got just from listening to you.
MYERS
Well tell us then.
WALLACE
You have a rotator cuff tear. The tendon that we've just been talking about being inflamed, in your case that tendon has torn and that's why you need to use your other arm to lift your - you need to use your good arm to lift your bad arm up and it's a classic feature. The other thing you'll probably be aware of, although you haven't thought about it, is that you'll probably find that your arm has been weak and you're not quite able to do the things with it you're used to.
KITTY
Yeah I have in the past had frozen shoulder and I just used to like put Tubigrip on because it seemed the pain was between the shoulder and the elbow and muscular and then resting it of course then I could use it again. But this time, this has been - I've had this like a few months now. I am waiting for an ultrasound in January.
WALLACE
Well firstly you've identified that pain in the shoulder is actually not felt in the shoulder, it is often felt in the upper arm and as it becomes more severe it goes down the arm and you can actually have shoulder pain felt at the elbow and even into the forearm when it's severe. So people don't understand this. I had a patient in clinic this morning, she said my pain is in the arm doctor, it's not in the shoulder and I had to explain well unfortunately your mind, your brain, can't work that out and you're actually feeling shoulder pain but it's in the wrong place.
MYERS
So it's time really Kitty got some treatment for this by the sound of it?
WALLACE
I would certainly recommend that she is referred to an orthopaedic or shoulder surgeon for an assessment because she is a candidate for a possible shoulder - rotator cuff repair operation.
MYERS
And what would that involve?
WALLACE
It's quite a big operation and it means that we find the torn tendon, we sew it back to the bit of bone that it pulled off and then we have to protect the arm for between four and six months - four and six weeks - with a sling. Then you get going with a physio programme. So if you are going to have rotator cuff repair surgery it takes three months out of your life because you have to have the operation, you've got the initial splintage and then you've got the rehabilitation with a lot of physiotherapy.
MYERS
And what can you expect by way of results from that procedure?
WALLACE
We look - we see 70-80% good results from rotator cuff repair surgery. That does mean that we've got 10% who do not benefit and 10% who only get some benefit. But for people who, for instance, play golf and can't play golf because of their torn rotator cuff they are delighted when they can return to golf afterwards. And it is an operation which we are getting better and better at doing and it can now be done keyhole whereas going back 10 years ago we weren't doing it keyhole.
MYERS
And if your ambition is no more than to be able to reach to the top shelf or perhaps tie a necklace or something, that's ...
WALLACE
Well there is a debate there because I think the surgeon has to sit down with the patient and explain to the patient, look there is this big operation, do you want it, or shall we give you a lesser treatment - and that can be shaving a little bit of bone away - that will give you pain relief but will leave you a little bit weaker.
MYERS
And just to say that it's just after quarter past three, you're listening to Check Up, I'm Barbara Myers and I'm talking today to Professor Angus Wallace, we're talking about problem shoulders. And Rachel is on the line next, again wanting, I think, to talk about rotator cuff injury. You're having or have had physio for this I think Rachel and how's that worked or has it not?
RACHEL
Well it's actually my husband that I'm phoning for. He's - in fact it sounds very much as though he might be a candidate for that operation which will terrify him. But he's - he has been to the GP, he's had the injection that Professor Wallace was talking about and has had actually no relief from that. He's also been to physiotherapy and had acupuncture and nothing seems to work and it's now getting to the stage where he's actually crying with pain sort of in his sleep and it's disrupting me quite a lot as well.
MYERS
Well I'm really sorry to hear that, that sounds bad.
RACHEL
He can't even put his - put his jacket on without severe problems. So the question I really wanted to know was which is the best way to go, I mean is it best to go back to the GP and sort of ask for more or continue with the physiotherapy? He's had conflicting advice because some people have said don't rest, don't work - he used to go to the gym and things - and they said don't work it and it's best to rest it and then other people have said these are the exercises and try these but nothing seems to be working.
WALLACE
Age is very important for me because different conditions occur at different ages. How old is your husband?
RACHEL
He's 52.
WALLACE
Fine. So that he could have impingement or it could be a rotator cuff tear - it'll be one of these two. Probably from your story it's more likely to be a tear and he should be referred by his GP to an orthopaedic surgeon for an assessment but the GP may wish to order an ultrasound scan of the shoulder, which is a good and effective way - not too expensive - of showing whether there is a rotator cuff tear or not.
RACHEL
That's very helpful thank you very much.
MYERS
Thanks for that call and sorry to hear he's in a lot of pain. So that's a case where at least the painkillers are going to be worth taking. But there's obviously something a little bit more fundamental that can be done. So that would lead perhaps to this operation that you've been talking about, to repair the rotator cuff?
WALLACE
Yes a 52 year old man is the sort of ideal patient for considering because they want to carry out a normal life, they usually want to continue with sport and continue in the gym and in order to do that the best treatment is to put the torn rotator cuff back where it came from and fix it there and we fix it there with stitches, sutures, and nowadays we tend to use things we call anchors, which are little studs that we put in the bone to help fix it.
MYERS
Rachel raised a point in I think perhaps a lot of people's mind and that is whether you should rest or exercise and obviously that in her husband's case has got to the point where he needs something more fundamental. But generally speaking for people wondering if they've got a sore shoulder whether they should rest, whether they should exercise, whether they should use compresses - hot or cold - are any of these things of any use?
WALLACE
Well first of all if you have an acute injury the best thing to apply to the shoulder is cold and the cheapest and easiest thing to get hold of are a bag of frozen peas and apply that to the shoulder. Now that's for an acute injury. But most of these are chronic injuries and they tend to respond I think slightly better to heat and therefore a hot pad. There are nice ones that you can actually put in the microwave, heat up in the microwave, and apply to the shoulder, will help. The best way forward, however, is graduated exercises below shoulder level, trying to improve the strength of the muscles because what is happening is that the ball of the shoulder joint is tending to move upwards in a slightly uncontrolled way and if you can get the muscles to work together to hold the ball centrally on the socket then you reduce impingement and you reduce pain.
WALLACE
Thank you. Let's go to Julian, who I think has got a dislocated shoulder, is that the case Julian?
JULIAN
Not quite, I've had two previous dislocated shoulders, it sounds like what the gentleman was talking about earlier where it partially came out and went back in quite quickly. And the last one happened about 18 months ago and I had some physio and I've had some anti-inflammatories. But now when I exercise it does tend to be quite sore, for example it's quite sore at the moment after working out last week.
WALLACE
Okay Julian, you sound as if you're probably under 30.
JULIAN
Thirty three, thanks for ...
WALLACE
Thirty three, right. You're the sort of age where we do see people who have had a dislocated shoulder and then go on to have what we call instability symptoms. Now that means the shoulder is partially dislocating when you exercise. And that can be improved with strengthening exercises but if it doesn't respond to strengthening exercises - and you've told me that you've been working in a gym...
JULIAN
Yeah I have done quite a lot of exercise, nothing too dramatic, if it's sore then I'll rest it and then I'll try again gently and the pain comes back.
WALLACE
There is a very successful operation with a greater than 90% cure rate that can be done as a keyhole operation from which there's a fairly quick recovery which is likely to cure you and therefore if you were to continue to have this grumbling problem and you got fed up with it report to your own doctor, say that I said you might want to be sent to an orthopaedic surgeon and he'll look at you and assess whether you have, what we call, instability or partial dislocation.
MYERS
Forgive me for jumping in I want to go very quickly, if I may, to another caller. Mark is in Sunderland and wondering about a replacement operation, I don't know if this is something for which you've been told you're a candidate Mark, how can we help you with that?
MARK
Yes, thank you. I have a diagnosis. I fell off a bicycle about eight months ago on an icy road, bashed my shoulder very hard, didn't realise at the time I'd fractured it, what's called a proximal fracture which has resulted in the ball part of my right shoulder joint being depressed. So naturally I have very restricted movement and clearly need corrective surgery of some type. Having had a CT scan I'm waiting to see my consultant again but she's already muted the possibility - one option of being a replacement shoulder joint. I wanted a bit more information about that please and what you thought.
WALLACE
Right Mark, this is a problem. What has happened is that the shape of the ball has changed as a result of the fracture. The ball is now in the wrong place and even although the muscles are all there and doing the right thing, the mechanics are no longer working. And so what is needed is to get the ball back into the right place and it is probable, but not definite, that the best thing would be a shoulder replacement. Now a surface replacement means that you're put on a cap where the shoulder ball originally was, that doesn't always fit when you've had a fracture and you may have to consider a conventional stemmed prosthesis. So think about it. People are worried about how long shoulders last, they don't need to, shoulders last 25-40 years, the results are pretty close to hip replacement and so it is something that you should seriously discuss with your orthopaedic surgeon.
MYERS
Thank you very much. Thank you for the question Mark. Thank you to my guest today, we're out of time. Thanks to everyone who's called in. I'm very sorry, once again, if we haven't managed to get to your particular question but do follow up by contacting our free and confidential help line, 0800 044 044 or go of course to the Check Up website. And join me again next week, we'll be taking your calls on cholesterol.
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