1. Treatment Options for Shoulder Pain

2. Anatomy of the Shoulder Made up of 3 bones: Scapula (shoulder blade) Scapula (shoulder blade) Humerus (upper arm bone) Humerus (upper arm bone) Clavicle (collarbone) Clavicle (collarbone) ( Collarbone ) (Shoulder Blade) (Upper arm bone)

3. Shoulder Facts Most complex joint in the body. Most complex joint in the body. One of the few joints with 360 degrees rotation. One of the few joints with 360 degrees rotation. Extensive array of ligaments and muscles. Extensive array of ligaments and muscles.

4. Shoulder Joint Healthy shoulder joint Healthy shoulder joint n Arthritic shoulder joint

5. Causes of Shoulder Pain Osteoarthritis (wear and tear) Osteoarthritis (wear and tear) Rheumatoid arthritis Rheumatoid arthritis Rotator cuff tears Rotator cuff tears Shoulder impingement (bursitis and tendonitis) Shoulder impingement (bursitis and tendonitis) Repeated dislocations or fractures Repeated dislocations or fractures Trauma Trauma

6. Symptoms of Shoulder Arthritis Pain: Pain: Centered in the back of shoulder if glenohumeral shoulder joint is affected. Centered in the back of shoulder if glenohumeral shoulder joint is affected. Focused on the front of the joint if AC joint is affected. Focused on the front of the joint if AC joint is affected. Rheumatoid arthritis will affect both of these areas. Rheumatoid arthritis will affect both of these areas. Reduced/Loss of range of motion Reduced/Loss of range of motion Grinding or catching sensation Grinding or catching sensation Stiffness Stiffness

7. Preparing for Examination Have the following information ready for your exam: Have the following information ready for your exam: Chief complaint (Where it is hurting the most?) Chief complaint (Where it is hurting the most?) Chronology of illness Chronology of illness What effect does the pain have on your life? What effect does the pain have on your life? Family history Family history

8. Diagnosing Shoulder Arthritis Physical examination Physical examination Medical history review Medical history review Strength and Motion test Strength and Motion test X-Rays X-Rays Arthrogram Arthrogram Magnetic Resonance Imaging (MRI) Magnetic Resonance Imaging (MRI) Blood tests Blood tests Blood Count Blood Count Rheumatoid Factor for rheumatoid arthritis Rheumatoid Factor for rheumatoid arthritis C-Reactive Protein C-Reactive Protein

9. How Can My Life Change with Treatment? A return to mobility. A return to mobility. Regaining a sense of your former lifestyle. Regaining a sense of your former lifestyle. A change in your pain symptoms A change in your pain symptoms

10. Non-surgical Treatment Options for Shoulder Pain: Over-the-Counter Medications Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) Usually first drug used to treat arthritis Usually first drug used to treat arthritis Can reduce pain, swelling and redness Can reduce pain, swelling and redness Relief can take several months Relief can take several months Examples: Examples: ibuprofen ( Advil®, Motrin®) ibuprofen ( Advil®, Motrin®) naproxen ( Aleve®) naproxen ( Aleve®) Aspirin Aspirin Reduce joint pain and inflammation Reduce joint pain and inflammation Form of NSAIDs Form of NSAIDs

11. Non-surgical Treatment Options for Shoulder Pain: Over-the-Counter Medications Acetaminophen Reduces pain Reduces pain Lowers fever Lowers fever Does not reduce inflammation of arthritis Does not reduce inflammation of arthritis Examples: Examples: Tylenol ® Tylenol ® Datril ® Extra Strength Datril ® Extra Strength Tempra ® Tempra ®

12. Non-Surgical Treatment Options for Shoulder Pain: Prescription Medications NSAIDS NSAIDS Most popular type for osteoarthritis treatment Most popular type for osteoarthritis treatment Includes ibuprofen ( Motrin ® ), naproxen sodium ( Anaprox ® ), oxaprozin (Daypro ® ), sulindac (Clinoril ® ), etc. Includes ibuprofen ( Motrin ® ), naproxen sodium ( Anaprox ® ), oxaprozin (Daypro ® ), sulindac (Clinoril ® ), etc. Analgesics Analgesics Provide pain relief, but do not reduce inflammation Provide pain relief, but do not reduce inflammation Includes Acetaminophen with codeine (Tylenol ® with Codeine), Oxycodone (OxyContin ®, Roxicodone ® ), Hydrocodone with acetaminophen (Vicodin ®, Dolacet ® ), etc. Includes Acetaminophen with codeine (Tylenol ® with Codeine), Oxycodone (OxyContin ®, Roxicodone ® ), Hydrocodone with acetaminophen (Vicodin ®, Dolacet ® ), etc.

13. Non-surgical Treatment Options for Shoulder Pain: Prescription Medications Biological response modifiers Biological response modifiers Treat rheumatoid arthritis; may postpone injury to the joints Treat rheumatoid arthritis; may postpone injury to the joints Includes: Infliximab (Remicade ® ), Etanercept (Enbrel ® ) Includes: Infliximab (Remicade ® ), Etanercept (Enbrel ® )Remicade ® Remicade ® Glucocorticoids or corticosteroids Glucocorticoids or corticosteroids Treat rheumatoid arthritis; fight inflammation Treat rheumatoid arthritis; fight inflammation Includes: cortisone, hydrocortisone (Cortef ®, Hydrocortone ® ), Prednisolone (Prelone ® ) Includes: cortisone, hydrocortisone (Cortef ®, Hydrocortone ® ), Prednisolone (Prelone ® ) DMARDS DMARDS Treat rheumatoid arthritis; slow joint destruction Treat rheumatoid arthritis; slow joint destruction Includes: methotrexate, injectable gold, penicillamine (Depen ® ), Azathioprine (Imuran ® ), etc. Includes: methotrexate, injectable gold, penicillamine (Depen ® ), Azathioprine (Imuran ® ), etc.

14. Non-surgical Treatment Options for Shoulder Pain Cortisone injections Cortisone injections Powerful anti-inflammatory medication Powerful anti-inflammatory medication Temporary pain relief lasting several weeks to months Temporary pain relief lasting several weeks to months Small risk of infection Small risk of infection Activity modification Activity modification Assistive devices, such as reachers Assistive devices, such as reachers Physical therapy Physical therapy

15. Surgical Options for Shoulder Pain Synovectomy Synovectomy Arthroscopy Arthroscopy Soft tissue repair Soft tissue repair Shoulder replacement surgery Shoulder replacement surgery Reverse shoulder replacement Reverse shoulder replacement Hemiarthroplasty Hemiarthroplasty Total shoulder replacement Total shoulder replacement

16. Synovectomy Early stages of rheumatoid arthritis. Early stages of rheumatoid arthritis. Removes inflamed tissue lining. Removes inflamed tissue lining. Potentially saves joint from further damage. Potentially saves joint from further damage.

17. Synovectomy, continued Small incision is made. Small incision is made. Arthroscope is used to inspect the joint. Arthroscope is used to inspect the joint. Diseased synovium is removed. Diseased synovium is removed. Sling may be required. Sling may be required. Physical therapy usually required. Physical therapy usually required.

18. Synovectomy, continued Benefits Alleviates rheumatoid arthritis pain in the joint Alleviates rheumatoid arthritis pain in the joint Joint may be saved from further damage Joint may be saved from further damage Synovium could grow back over time Synovium could grow back over timeDisadvantages Not a permanent solution Not a permanent solution

19. Arthroscopic Surgery Used when osteoarthritis causes small pieces of cartilage to wear away from joint and float around. Used when osteoarthritis causes small pieces of cartilage to wear away from joint and float around. Removes any debris and smoothes cartilage surfaces. Removes any debris and smoothes cartilage surfaces. Potentially saves joint from further damage. Potentially saves joint from further damage.

20. Arthroscopic Surgery A small camera is inserted into the shoulder through small incisions, allowing the doctor to see inside the joint. A small camera is inserted into the shoulder through small incisions, allowing the doctor to see inside the joint.

21. Arthroscopic Surgery Benefits Less invasive option may lead to shorter recovery time Less invasive option may lead to shorter recovery time Smaller incisions Smaller incisions Can be performed on an outpatient basis Can be performed on an outpatient basis Risks (common to all surgeries) Infection Infection Excessive bleeding or swelling Excessive bleeding or swelling Formation of blood clots Formation of blood clots Damage to adjacent tissue Damage to adjacent tissue

22. Soft Tissue Repair Tissue patch used to reinforce rotator cuff repair. Tissue patch used to reinforce rotator cuff repair. Fixes over an area of weakened or damaged soft tissue. Fixes over an area of weakened or damaged soft tissue. Provides a framework for new tissue to grow. Provides a framework for new tissue to grow. Gradually the patch disappears until only your own tissue remains. Gradually the patch disappears until only your own tissue remains.

23. Soft Tissue Repair, continued Benefits Adds strength and durability to tissue Adds strength and durability to tissue Less-invasive Less-invasive Risks (common to all soft tissue repairs) Infection Infection Instability Instability Increased stiffness Increased stiffness Adhesions Adhesions

24. When is Shoulder Replacement Surgery Right for You? Experience significant pain. Experience significant pain. Reduced or loss of function despite non-surgical treatments. Reduced or loss of function despite non-surgical treatments. Quality of life has significantly changed. Quality of life has significantly changed. Medications for pain are no longer effective. Medications for pain are no longer effective.

25. Total Shoulder Replacement There are over 16,000 shoulder replacements each year. 1 There are over 16,000 shoulder replacements each year. 1 Surgeon will decide the type of shoulder replacement. Surgeon will decide the type of shoulder replacement. Choice is based on age, lifestyle and the surgeon’s experience. Choice is based on age, lifestyle and the surgeon’s experience. 1. www.jointreplacement.com

26. Shoulder Replacement Components The metal humeral component replaces the ball on the top of the stem and fits into the upper arm bone. The metal humeral component replaces the ball on the top of the stem and fits into the upper arm bone. The plastic glenoid component replaces the socket of the shoulder. The plastic glenoid component replaces the socket of the shoulder.

27. Shoulder Replacement Depending on the damage, the surgeon may replace: Depending on the damage, the surgeon may replace: Only the humeral head (hemiarthroplasty) Only the humeral head (hemiarthroplasty) Both the humeral head and glenoid Both the humeral head and glenoid

28. Reverse Shoulder Replacement Designed for end-stage cuff tear arthropathy sufferers Designed for end-stage cuff tear arthropathy sufferers Extreme shoulder degeneration; cannot function normally Extreme shoulder degeneration; cannot function normally May improve motion and stability by changing shoulder mechanics May improve motion and stability by changing shoulder mechanics

29. Reverse Shoulder Replacement, continued Because the shoulder mechanics have been reversed, the stronger muscles can now lift the arm. Because the shoulder mechanics have been reversed, the stronger muscles can now lift the arm.

30. Reverse Shoulder Replacement Candidates Recommended for patients: Recommended for patients: Age 70 years or older Age 70 years or older Experience significant pain Experience significant pain Have little to no movement in their shoulder Have little to no movement in their shoulder Not Recommended for patients: Not Recommended for patients: With bone disease, deficiencies in the scapula or non-functioning deltoid muscles With bone disease, deficiencies in the scapula or non-functioning deltoid muscles Younger or physically active Younger or physically active

31. Potential Benefits to Patients from Surgery Return to mobility Return to mobility Restore their lifestyle Restore their lifestyle Freedom Freedom Individual results may vary. There are potential risks and recovery can take time. The performance of any new joint will depend on your weight, activity level, age and other factors.

32. Surgical Procedure Patient is anesthetized. Patient is anesthetized. Incision is made on the shoulder. Incision is made on the shoulder. The ball portion of the humeral head is removed. The ball portion of the humeral head is removed.

33. Surgical Procedure, continued The humeral and glenoid implant components are inserted. The humeral and glenoid implant components are inserted. Incision is closed. Incision is closed. A shoulder splint or immobilizer may be worn after surgery. A shoulder splint or immobilizer may be worn after surgery.

34. Preparing for Joint Replacement Surgery Ease anxiety by mentally preparing with: Ease anxiety by mentally preparing with: Breathing exercises Breathing exercises Meditation Meditation Imagery Imagery Talking with friends and family Talking with friends and family Learn more about shoulder replacement surgery: Learn more about shoulder replacement surgery: Brochures Brochures Handouts Handouts Websites Websites Videos Videos

35. The Night Before Surgery Avoid medications, such as “blood thinners” (aspirin, ibuprofen, etc.). Avoid medications, such as “blood thinners” (aspirin, ibuprofen, etc.). Do not consume any food or liquid after midnight. Do not consume any food or liquid after midnight. Make sure you have everything you’ll need at the hospital. Make sure you have everything you’ll need at the hospital. Ask any questions you may have before surgery. Ask any questions you may have before surgery.

36. After Surgery Switch to a pain medicine taken by mouth after a day or so. Switch to a pain medicine taken by mouth after a day or so. Gentle basic range-of-motion exercises begin after leaving recovery room. Gentle basic range-of-motion exercises begin after leaving recovery room. Two in-patient treatments per day while in hospital. Two in-patient treatments per day while in hospital.

37. Hospital Discharge You will be released from the hospital as soon as: You will be released from the hospital as soon as: The incision is dry. The incision is dry. Comfortable taking only oral pain medication. Comfortable taking only oral pain medication. Able to perform the range of motion exercises. Able to perform the range of motion exercises. Home support system is in place. Home support system is in place. Average recovery period lasts three to six months. Average recovery period lasts three to six months.

38. A Caregiver’s Role Provide support and show patience Provide support and show patience Help with needs that the patient can not do, like: Help with needs that the patient can not do, like: Meal preparation Meal preparation Grocery shopping Grocery shopping Laundry Laundry Driving to medical appointments Driving to medical appointments

39. Physical Therapy After Surgery Begins one day after surgery. Begins one day after surgery. Starts with information gathering about day-to-day problems, testing strength, range of motion, palpation, etc. Starts with information gathering about day-to-day problems, testing strength, range of motion, palpation, etc. Develop a treatment plan. Develop a treatment plan.

40. Recovery in the First Week Expect personal limitations on activities. Expect personal limitations on activities. Important to limit any sudden or stressful movements to your shoulder. Important to limit any sudden or stressful movements to your shoulder. May be required to wear a sling or protective device for at least a month after surgery. May be required to wear a sling or protective device for at least a month after surgery.

41. Recovery in the First Month Stitches are removed seven to 10 days after surgery. Stitches are removed seven to 10 days after surgery. A formal physical therapy program begins 10 to 14 days after surgery. A formal physical therapy program begins 10 to 14 days after surgery. Shoulder should continually improve up to six months after surgery. Shoulder should continually improve up to six months after surgery.

42. Recovery After Six Weeks Ability to return to work will depend on progress and type of work. Ability to return to work will depend on progress and type of work. Driving should wait until you can perform the necessary functions comfortably. Driving should wait until you can perform the necessary functions comfortably. No contact sports or any heavy lifting for at least six months. No contact sports or any heavy lifting for at least six months.

43. Questions?

44. Thank you!