The Trouble with Shoulder Pain…

Shoulder pain can be a real pain! This is true if you suffer from it or are trying to fathom what’s causing it. Sometimes what seems obvious is not the real root cause of the pain. Many conditions can mask the primary problem which leads to the treating symptoms rather than the pathology – a recipe for lack of long-term happiness.

The shoulder has a habit of not obeying the rules. Unlike other joints in the body, there is no clear path of treatment for many shoulder complaints, and you often find experienced shoulder physicians treating the same condition very differently. This means there is no absolute ‘right’ or ‘wrong’ for a whole host of conditions, such as impingement, rotator cuff failure, certain types of instability and even many common problems such as fractures, arthritis and joint replacement. Very little is standardised, surgical thinking varies enormously, and the use of alternative therapies is extremely variable.

This means that two friends having a chat may discover that they both have the same diagnosis, but are receiving very different treatments.

There isn’t a right or wrong in managing shoulder problems. This is confusing for trainees, patients, insurers, commissioners of healthcare and, most of all, for patients.

Why is this so? Are shoulder physicians all slightly nuts; do they not understand their subject? The answer is somewhat complex and relates to softer issues other than just a diagnosis. Correct treatments for a condition must be those that the surgeon has experience and confidence in, and must also suit the patient and provide a particular outcome in line with expectations. Treatments also need to be explained, with expected time scales and common side effects understood. There are occasionally significant side effects which can arise from effective treatments. These are not the same as complications, which are unexpected and mostly unavoidable. Side effects include slow or incomplete resolution of pain, stiffness or weakness.

So the resolution of the problem may take a different path from consultation to consultation. The tools on offer to help are fairly standard: activity modification, medication, Physiotherapy, injections or surgery. What does vary, and what experience teaches you as a physician, is how and when to use these tools, and how to guide your entrusted patient through the therapy to a successful outcome.

Usually best choice is to use treatments that have fewer unwanted consequences, and progress to treatments with more significant implications only when other treatments have not worked.

However, there are often individual preferences and imperatives that may bring more risky treatments straight to the front of the queue. Frozen shoulder is such an example. This is a condition that has a multitude of treatment options, all of which can be applicable. It is normally a self-healing condition, but this can take years. Injections can help control pain while resolution occurs. Physiotherapy and acupuncture also can provide some comfort. Surgery is useful in cases with a need for rapid return or increased movement. So, there are choices for treatment options and they may combine to be correct for different individuals.

These choices exist for almost all shoulder conditions but are more influenced by need, personality, lifestyle and expectations of the sufferer than by the ‘diagnosis’. These factors also affect the outcomes of our interventions significantly. This concept is a bit of a fly in the ointment of scientific research and protocols for treatment. Delivering healthcare is becoming more protocol-driven to enable automated decision making by less experienced health care professionals.

It is quite obvious that protocols and algorithms may not lead to optimal care for shoulder pain sufferers, because of the variables discussed above. Consequently, it will not be the same for everybody. It is therefore fairly important to have discussions with your physician about all aspects of your life when seeking help for your shoulder pain, and to ensure that they are listening to you. Do not be misled by people offering miracle cures and make sure you deliver your needs and concerns to your physician carefully. Together they should be able to navigate you through a path to recovery and comfort. Applying the individualised treatment options will meet the needs of each different person suffering from shoulder pain, but simply following treatment protocols, often financially driven, may result in poor care and worsening of the problem.

Mr Dan Russouw is a Consultant Orthopaedic Surgeon who specialises in shoulder conditions and treatment. Alongside his private work at Total Orthopaedics, he continues to practice at Barnet and Chase Farm NHS Trust. He teaches surgery at the Royal College of Surgeons and has also recently joined the Orthopaedic faculty at the Royal Free London NHS Foundation Trust.

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Some consider eradication of infection in orthopaedic surgery as the next frontier for our profession. Studies like these help us push forwards. 👏 to the authors.

Very high quality paper showing that surgery isn’t the answer.