Anatomy of the Shoulder
The shoulder joint, like many joints, is a complex network of bones, muscles, tendons, cartilage and ligaments. The three bones that make up the shoulder are the scapula (shoulder blade), the humerus (arm bone), and the clavicle (collarbone).
The shoulder is a ball-and-socket joint, meaning that the top of the humerus meets the scapula in a portion where there is a socket called the glenoid. Ball-and-socket joints are structured so that the attached limbs can have a wide range of motion. This type of joint also occurs in the hips and has an equally impressive range of motion there.
Between the bones of the shoulder joint is a significant amount of cartilage. The humerus is covered in articular cartilage, and the glenoid has a piece of cartilage called the labrum. The bursa is a small sac full of fluid that helps the joint move smoothly. The purpose of these types of cartilage is to ensure that the joint can glide smoothly during activity. If the cartilage begins to break down or becomes torn, the bones will begin to rub against one another and cause pain.
The role of keeping the joint in place falls to the rotator cuff. The term “rotator cuff” refers to a grouping of muscles and tendons that surround the joint to provide stability by keeping the ball in the socket.
All of these small pieces make up the greater shoulder joint. Each tissue can also become damaged or injured, causing pain and discomfort. Chronic pain can be manageable, but when it becomes unbearable or begins to interfere with daily life, it is time to see a doctor.
Shoulder pain can be chronic or only occur during certain activities. It can be a short, sharp pain, or it can be a dull ache – or anywhere in between. Some of the most common causes of shoulder pain are:
- Broken Bones
Diagnosing Shoulder Injury
Initially, doctors will want to know about medical history, previous injuries, occupation, and more. They will ask questions about what symptoms are occurring and where the pain is located. It is important to be as honest as possible during this portion of the examination, as information that may not seem relevant can be used to inform a diagnosis.
Testing begins with a physical evaluation. Doctors will observe the shoulder joint and look for any abnormalities or swelling. They will then observe the strength and range of motion that the shoulder has. Doing so could determine the cause of pain, but most doctors will order more intensive testing to determine the exact cause:
- MRI: Magnetic Resonance Imaging can provide doctors with an image of the soft tissues in the joint. If pain is being caused by damage to the soft tissue, MRI will usually be able to spot it.
- X-Ray: this type of imaging allows doctors to see the bones within a joint. If pain is being caused by damage to the bones, an X-Ray will detect this. Some shoulder pain can be caused by an abnormality in bone structure that places stress on the surrounding soft tissue; an X-Ray would be able to detect this as well.
- CT Scan: Computed Tomography scans are able to produce a cross-sectional image of an area. This can help doctors see how the structure is impacting other areas of the joint.
- EMG: Electromyography is a test that determines how healthy and functional the nerves are. It sends small electrical pulses down the arm and times them. If the pulses take longer to reach the hand, this is indicative of nerve damage.
Shoulder pain that is addressed in its early stages can often be treated using nonsurgical methods. In some cases the initial injury is severe enough that surgery is necessary early on. Consulting with a doctor and receiving an accurate diagnosis are the first steps in the recovery process.
Conventional Treatments of Shoulder Pain
Each potential injury has its own recovery process. Recovering from tendonitis may be different than recovering from arthritis, for example. Doctors will know which treatment plan is best for each patient depending on their needs.
Many shoulder injuries respond well to initial nonsurgical methods of treatment. The specifics may change, but generally the most common treatments are:
- Rest: simply resting the joint and avoiding activities that induce pain can be enough for it to heal on its own. This is generally recommended throughout the healing process, but for some, it is all they need. Patients with minor injuries who rest the joint can see results within one week.
- Altering Activity: avoiding activity or doing it in a different way (by exercising different muscles) could be enough to relieve symptoms in some patients. This is especially true when shoulder pain is caused by overuse or repetitive motion.
- Physical Therapy: the goals of physical therapy are to strengthen muscles surrounding the shoulder joint, which provides stability. For patients who are experiencing chronic dislocations, tendonitis, or impingement, this is a good option. It should be noted that certain shoulder conditions such as a fracture benefit more from rest than exercise – be sure to consult a doctor before undergoing physical therapy to ensure that it is a proper treatment.
- Pain Relief: applying ice to the injury and taking anti-inflammatory drugs such as Ibuprofen can reduce pain. Reducing pain can allow patients to go about their daily lives, and it can make physical therapy easier. Doctors sometimes prescribe painkillers. Prescription painkillers should be only taken as it is directed.
- Corticosteroid Injections: a powerful anti-inflammatory injection can relieve pain. This shot can cause long-term tissue damage, however, so it is not for everybody and should always be closely monitored by a professional.
- Surgery: shoulder surgery can come in many forms. It is typically seen as the final option for treating shoulder pain, and is only suggested if a patient has tried nonsurgical treatment methods but experienced little to no pain relief. The two major types of surgery that are performed are Arthroscopy and Open Surgery.
- Arthroscopy: surgeons use a tool with a tiny camera on the end to enter the joint and observe the tissue. This can be used as a diagnostic method. In most cases, arthroscopy involves the use of other small tools that correct the tissue with the guidance of the camera. This may include removal of damaged tissue, reshaping the bone, and repairing soft tissue. Arthroscopy is less invasive than open surgery and often has a shorter recovery period.
- Open Surgery: the term “open surgery” refers to surgery that is performed with a major incision. This can include rotator cuff repair or total shoulder replacement. Arthroscopy is generally less invasive than open surgery, so it is not always the first choice. Certain conditions and the patient’s needs may factor into whether medical professionals decide to do open surgery or arthroscopy.
Treatment plans will look different from one patient to the next. Dedication and commitment to the plan can result in symptom relief and a lower chance of injury later in life. While it is not fatal to deviate from the recovery plan, it can cause symptoms to worsen and create complications later in life.
Making the Decision
Many shoulder surgeries are elective, meaning that it is the patient’s decision to have surgery or not. Throughout the entire recovery process it is important to maintain dialog with medical professionals. They can help to address any questions that may arise and can explain the surgery to the extent that the patient is comfortable.
Many factors may influence a patient’s decision to undergo surgery, including money, taking time off of work, extent of daily disruption, and support system. Knowing what to expect before, during, and after surgery can be extremely beneficial to a patient. Being aware of what exactly is going to happen and the potential risks can greatly ease any anxiety or stress that comes with making the decision.
Understanding the risks of surgery is important going in – these include infection, blood clots, or a reaction to anesthesia – though they may be more risks that are important to discuss with professionals.
Shoulder Replacement Surgery Recovery Timeline
Every recovery is different depending on a patient’s condition and willingness to participate in post-operative care. The following recovery timeline is based on a typical recovery process, but it may not reflect yours exactly. This is a guideline meant to help total shoulder replacement surgery patients understand what to expect. Always ask your doctor or surgeon if any questions arise. An average recovery timeline is as follows:
- Preparing for Shoulder Replacement Surgery: certain steps need to be taken before the operation begins. This may include scheduling blood work or other tests, arranging a ride home from the hospital, taking time off of work, and bringing a change of comfortable clothing. For shoulder surgery, avoid clothing that will be difficult to maneuver with a postoperative shoulder. Many doctors suggest clothing with buttons or zippers instead of pullovers. It may be necessary to stop eating and drinking for a certain period of time before the operation. Many patients take this time to ensure that their home is accessible by placing objects within arm’s reach, installing a shower chair, and preparing their wardrobe, for example.
- The Procedure: total shoulder replacement surgery involves removing the damaged ends of the shoulder blade and arm bone. Prosthetic joint components are then placed into the bone using a type of cement. These prosthetics are made of metal and plastics and intend to serve the same function of a healthy joint. The shoulder is tested for mobility before the incision is closed. An anesthesiologist will be present to apply general anesthesia, and possibly local anesthesia to help with pain in the hours after surgery. The biggest risks of anesthesia are stroke, blood clots, and pneumonia.
- Two Hours After Surgery: the first couple hours after surgery are spent in a recovery room while the anesthesia wears off. Once the patient is awake, they will be moved to their own hospital room to continue recovery. The hand and arm may not have any feeling, but if it is possible to move them, it is recommended to do so.
- 1-2 Days After Surgery: patients will likely spend the first couple days after surgery in their hospital room. The arm is placed in a sling. Many medical professionals will be involved in this process, including nurses, doctors, and case workers. Physical therapists will begin to show the patient exercises that they can do to maintain joint strength and stability as much as possible. Some patients are able to move their arm within the first day, others may take several days to begin movement.
- One Week After Surgery: physical therapy should begin as soon as the patient is able to participate. Physical therapists will work with patients to ensure that they are doing exercises properly so that they can do them at home. Exercising during this time may be difficult and painful, but it is a crucial part of the recovery process. Working out the shoulder muscles prevents stiffness and improves strength and mobility. Patients should ensure that there is a trusted person in their home to assist with daily tasks. The incision must stay dry during this time.
- Two to Four Weeks After Surgery: patients will begin to observe progress at this time. Pain and swelling should be slightly reduced. The wound, if closed, can begin to get wet again – it is important to monitor the incision for signs of infection, such as pus, bleeding, and redness. Physical therapy continues at this time.
- 6 Weeks After Surgery: patients at this time will observe increased mobility and minimal pain when resting. With a doctor’s permission, some patients begin to drive again at this time. It is not advisable to lift heavy objects, but physical therapists can guide a patient through what they are and are not capable of.
- 3 Months After Surgery: a follow-up with the surgeon at this time can provide patients with information about how they are healing. By the third month, most patients observe significant improvement in mobility.
- One Year After Surgery: with the continued guidance of medical professionals, most patients can return to their life as it was before the operation.
Factors that may impact the recovery timeline include age, obesity, diabetes, and smoking status. Though these factors can slow down the recovery process, it is still entirely possible – and even likely – that patients with these conditions make a full recovery.
Recovering from surgery can seem like a daunting task. It requires hard work and dedication as well as physical pain. The field of regenerative medicine offers hope for those who are considering surgery and those who have already undergone surgery alike.
The Role of Regenerative Medicine in Total Shoulder Replacement
The new field of regenerative medicine seeks to use a patient’s own cells to enhance the healing process. Using stem cells and platelet-rich plasma, these types of therapy offer pain relief and faster healing for those who have a shoulder injury, and people who have just had a total shoulder replacement. CELLAXYS offers two types of regenerative therapy:
- Stem Cell Therapy: this form of therapy begins with taking a patient’s stem cells, which are harvested using blood cells, fat cells, or bone marrow. The cells are then processed to be more concentrated, then reinjected into the shoulder. Stem cells contain healing properties that the body already sends to an injury. Placing a concentrated stem cell solution into a part of the body that is healing can help the damage heal faster. When coupled with total shoulder replacement, this therapy could allow the cut bone to heal more quickly as well as any damaged soft tissue nearby.
- Platelet-Rich Plasma Therapy: this form of therapy begins with a simple blood draw. The patient’s blood is then placed in a centrifuge to separate platelets from other components in the blood. The platelets are then injected into the injury or surgery site. Platelets contain proteins and growth factors that the body uses naturally to heal damage. Increasing the amount of these properties where damage has occurred could help the injury heal faster.
Each type of regenerative therapy comes with a low risk, as it uses the patient’s own cells. Some experience a slight pain at the injection site, but this typically goes away in a matter of days. Regenerative medicine can be a great option during the recovery process of shoulder replacement surgery. Using these therapies can make other recovery tasks like physical therapy more bearable by relieving pain.
It should be noted as well that some patients who have undergone these treatments have been able to surpass the need for surgery. In some cases, regenerative medicine can heal an injury to the point where surgery is no longer necessary. When this is the case, the recovery process is simplified drastically. The healing process for regenerative therapy is virtually nonexistent. It is still generally recommended that patients continue with physical therapy, as it can help in ways that regenerative medicine cannot.
The complex anatomy of the shoulder joint means that there are many different potential injuries. Some of the most common causes of shoulder pain are due to damage of the soft tissue. Soft tissue injuries are typically treated via nonsurgical methods. When the damage is significant enough, doctors may consider surgery to repair damage and even replace the joint completely. Shoulder replacement surgery is considered a major surgery, so making the decision should not be taken lightly. It is important to consider all of the options, as regenerative medicine may help the joint to heal enough that surgery is no longer necessary.