By Thomas E. Fithian, MD, FAAOS:
Patients with common shoulder disorders often assume they’ll require surgery to ease pain and improve stiffness, weakness and range of motion. Yet conservative measures – particularly exercise rehabilitation and physical therapy – often can provide amazing benefits.
In many cases of rotator cuff injuries, shoulder instability, and shoulder arthritis, there is no harm in delaying a trip to the operating room in favor of trying a nonsurgical approach.
The most frequent cause of shoulder pain is a rotator cuff disorder, generally seen in patients over 40. That includes full- or partial-thickness tears, tendinitis, and bursitis and impingement, all of which can interfere significantly with daily life.
As I’ve seen in my practice, research increasingly has indicated that for select patients, a combination of physical therapy, anti-inflammatory medications and possibly cortisone injections can delay or even eliminate the need for surgery.
One influential study was a Vanderbilt-led, multicenter examination of atraumatic full-thickness tears. The research, published in the Journal of Shoulder and Elbow Surgery in 2013, found exercise rehabilitation was an effective therapy in approximately 75 percent of patients followed for up to two years.
Physical therapy targets both the rotator cuff and small but important muscles around the shoulder blade, as well as core abdominal and lower back muscles. These exercises aim to improve joint mechanics and function and help compensate for damaged tendons.
Therapists teach range of motion, isometric, scapular stabilization and resistance exercises, as well as offer tips on posture, sleep positions, safe lifting and carrying techniques, and how to use heat, ice and anti-inflammatories for pain.
Most patients can learn enough in a few in-office sessions – sometimes just one – to continue therapy at home. If they don’t get relief, cortisone injections often are beneficial once an orthopaedist pinpoints the precise source of pain.
On a personal note, my own recurrent bouts of rotator cuff tendonitis have always responded to at-home exercises, allowing me to avoid injections or surgery.
Shoulder instability and dislocation, often found in younger patients and athletes, also frequently can be resolved by strengthening muscles around the joint. Exercises can be tailored to individual patients, such as baseball pitchers working to regain arm strength.
Arthritis in the shoulder, meanwhile, is much less likely to progress as rapidly as it does in weightbearing joints such as the knee and hip. Arthritic shoulders tend to be very responsive to cortisone injections, sometimes given as infrequently as once a year. I am not surprised if these patients go the rest of their lives without requiring a total joint replacement.
I have been a conservative surgeon throughout my 35 years of practice, but raising awareness of these methods is especially important to me now: in March, I stopped performing surgery to have a more flexible schedule. However, I am NOT retired! On the contrary, I expect to stay busy with diagnostics and nonsurgical treatments for upper extremity problems.
Should my patients require surgery, of course, referral to a colleague would be simple. Yet as our specialty continues to discover more about the most effective treatments for joint disorders, I predict conservative approaches will only gain ground.
Dr. Fithian is a fellowship trained shoulder specialist with Hampton Roads Orthopaedics Spine & Sports Medicine. hrosm.com