Board-certified orthopedic surgeon Elly LaRoque, MD, breaks down the three most common types of shoulder injury to facilitate efficient diagnosis and clarify treatment options. With cases to illustrate, she explains when to order MRI, when to start with PT, and when everything from acupuncture to injections to surgery is appropriate. Bonus: A look at the future of PRP and stem cell therapies.
Hello everybody. And so today I'm going to be talking about different causes of shoulder pain in the primary care patient. Mhm. Okay and just so just so you know um a lot of my partners also specialized in shoulder. So these are all of the um the shoulder specialists in the UCSF sports medicine department. Um Some of them as you can see our orthopedic surgeons and some of them are primary care sports medicine specialists. Um So the primary care sports medicine specialists will focus more on say ultrasound guided injections prp um non operative treatments and then the surgeons tend to focus a little bit more on um the surgical treatments. And the nice thing too is um our group has really expanded over the last couple of years and so we now see patients in um marin Berkeley and also san mateo. So not not just san Francisco anymore. Okay so today I'm going to be focusing on the shoulder and I'm going to cover a few topics. One is rotator cuff disease, another is adhesive capsule itis and another is labrum tearing or what we often call a slap tear. Okay, so we'll start with this first case. Uh This is a 50 year old woman, she's right handed, she has a history of type two diabetes and she presents with a three month history of severe left shoulder pain, no injury. But she's waking up at night due to pain. Her shoulder feels very stiff, she's having trouble reaching behind her and raising her arm above her head. On exam, she has no muscle atrophy and no point tenderness. There is decreased active and passive motion of the right Children. All planes and her rotator cuff strength is good. It's 505, although it is a little bit difficult for her to perform some of the physical exam. Strength testing due to limited range of motion and pain. Mhm. Okay. And then on her physical exam as you can see on the left side, her external rotation is very limited compared to her right. Okay. So how would you treat this patient? Um These are the choices. There are actually two answers which which I would consider. So for this patient um I would consider a physical therapy but also a cortisone injection. And I'll explain why my first choice would actually be a shoulder steroid injection. Okay. And so this patient has frozen shoulder or what we call it a capsule itis. And I'll show you the diagnostic decision tree for this. So in diagnosing frozen shoulder you want to look at active range of motion and also passive range of motion. So they're both decreased in frozen shoulder. And then often you want to get an X ray, not an MRI but just an X ray. If the X ray shows arthritis then you would think that the cause of their pain and stiffness is from ST Helena funeral arthritis. But if the X ray is normal then the answer is frozen shoulder. So this patient the X rays were normal so she has frozen shoulder. Now frozen shoulder can be very painful especially in the first few months to where the patients cannot tolerate physical therapy very well. So if you try to send them directly to physical therapy when they're in severe pain, often the physical therapists will send them back to us requesting an injection because if they have an injection even if it just helps temporarily sometimes that helps them participate in physical therapy a lot better. Um So adhesive capsule itis is a clinical diagnosis but usually you get an X ray to rule out blend of humor, all arthritis and it affects women more than men. If you have diabetes, it's much more common as well. So actually about five times more common in diabetic patients. It usually affects people ages 40 to 60. Um You do not need to Emory these people if they're X rays are normal and you think that they have frozen shoulder. In fact associated rotator cuff tears are very rare with with frozen shoulder. Um Again you want to consider getting X rays and then um if you have a frozen shoulder patient who has not been ever say tested for diabetes with a hemoglobin A one C. Um and also say has not been tested for any thyroid issues in quite some time. I would also recommend obtaining um uh diabetes markers and also some updated thyroid tests. Because sometimes those can actually be a risk factor for adhesive capsule itis. So there are three stages of adhesive capsule itis. The first stage is usually the first um say 3-9 months. That's a very painful phase. So that's the phase that this example patient was in. She has had pain for about three months. And so they tend to have a lot of pain and some decreased range of motion. They have painted rest also pain was sleeping. Then often they have less pain over time. So they reach this frozen phase where they just have hard endpoints with all of their ranges of motion. They're very stiff but not in as much pain. That's from about 4 to 12 months from onset of symptoms. And then they have a kind face That thawing phases anywhere from um usually about 1-3 years. And then they have less pain over time and gradual increase in range of motion. And if you look at the natural history studies for frozen shoulders um it usually doesn't resolve Until they're about 2-3 years out from onset of symptoms. So it can actually be a very frustrating thing for us to treat. So how do we treat it? Well we need your help and say optimizing diabetic control and we try to control the patient's pain with say anti inflammatories and also steroid injections. Um I put times too because sometimes we'll do cortisone injection in say the suburb cranial space to help the tendonitis component of this. And then oftentimes we'll also put an injection into the joint into the glen of funeral joint itself under ultrasound to help calm down the synovial or the joint lining. Um So often we do a total of say two injections. Um And then we also usually do order physical therapy to help restore the range of motion. But again often doing an injection first so the patient can tolerate therapy better. You can also consider acupuncture in these patients. I did a literature search for acupuncture with frozen shoulder and there is some good David to support it. Um And including one called bee venom acupuncture. But I'd say even just standard acupuncture, I would definitely consider for these patients if they're open to it. And then um there are some studies on capsule or dilation or distension injections where you inject fluid with or without cortisone into the Glennie funeral joint, even two point of capsule or rupture to try to improve motion. But the studies really show that there was that those injections only help temporarily. They can be very painful to the patient while they're occurring and they really don't do better after say a year compared to a regular cortisone injections. So I would say with UCSF we usually shy away from capsule or distension injections. Surgery for exclusive capsule itis is very rare. Okay we do it once in a while this. These are pictures from one of my patients with very refractory frozen shoulder that I ended up doing a manipulation and license of adhesions which is sort of like a scar tissue released surgery in the joint. Um I ended up doing that on her but that is it is very rare but you can just see that normally when we scoped shoulders we shouldn't see any redness. And this is the biceps tendon right here and here's the sub scapular is one of the rotator cuff tendons and you can just see all of the joint lining is just bright red and angry. So we try to not do surgery on these patients. Okay. And then how do cortisone injections work? We sometimes get a lot of questions about this from patients. And cortisone injections sometimes do get bad press. But I always just explain it's just an anti inflammatory injection. Uh and we think that they work by inhibiting cox two and fossil lead paste A. Two which are both inflammatory mediators. Okay so the next case um this is a 57 year old right hand dominant man who presents with right shoulder pain that started after he slipped and fell three months ago. He has pain in his lateral shoulder but deep to the deltoid. He's already tried physical therapy without benefit and he's waking up at night from sleep due to pain On exam. The shoulder is non tender. He has active range of motion intact but with pain at abduction between 60 and 120°.. So we call that painful arc. Um and he also has a lot of weakness with rotator cuff testing, so say four out of five strength with rotator cuff testing and his shoulder x rays are normal. Okay, so how would we treat this patient? So with this patient I would actually recommend going straight to getting a shoulder emery and I will explain why. So here are some of the key points in his history. So he's fairly young, I can say young, he's only 57 and he slipped and fell. So he actually had an acute traumatic injury to his shoulder. His pain is lateral deep to the deltoid. So to me that points to say superstar status in first tinnitus rotator cuff pain and he's already tried physical therapy and he's not better and he has a painful arc which points to rotator cuff pain and he is weak with rotator cuff testing. So usually these patients would be weak with, say abduction, forward flexion and external rotation. So with testing the super spontaneous and in first tinnitus, Okay, so in this patient going through the decision tree, it's different from frozen shoulder and glenn humor. All arthritis, right? Because he has actually good active and passive range of motion. So active and passive range of motion are both normal. So then we think about these other issues in the shoulder which could be causing his pain, but because he has that weakness four out of five strength with rotator cuff testing and he had an acute injury, we think about an acute rotator cuff tear and he's already failing conservative treatment, which is physical therapy. So that's why with him I would go straight to an MRI. Now rotator cuff disease is very, very common. Um the prevalence of shoulder pain in the general population is about 14-34%. And of these patients with shoulder pain, rotator cuff disease is a cause in about 65%. And rotator cuff disease incorporates a lot of different diagnoses. Okay, so um a couple of them are impingement, tendinitis, tendon apathy and bursitis. Um I actually lump those terms together and when I talked to my patients about a new diagnosis of say rotator cuff tendinitis, I always tell them that the terms bursitis and impingement are fairly interchangeable because maybe I would use one and they're physical therapist might use another. And we're really talking about the same thing. We also have partial thickness rotator cuff tears and full thickness rotator cuff tears. And just in terms of the shoulder anatomy. So this is the chromium, the roof bone up above the bursa and the rotator cuff. So here's the bursa and then we have the clavicle and the rotator cuff um consists of four different muscles and tendons. Okay. And then this is an example of a partial thickness tear. So I explained that to patients that if you picture the rotator cuff tendon being like a rope that the rope is just partially frayed through and a full thickness terror is where the rope is all the way torn through or the tendon is they pulled off of the human head bone. And so of this rotator cuff pathology are are decision trees are different depending on exactly what's going on. So impingement bursitis tendinitis, we try to treat these patients conservatively and often they'll respond just to conservative treatment. So physical therapy potentially say a sub microbial cortisone injection and medications such as anti inflammatories. Now, if somebody has a traumatic or symptomatic full thickness tear, like that patient example, that's when we want to get an MRI and we want you to consider an orthopedic surgery referral. Now this is a little more of a grey zone. So some patients have a partial rotator cuff tear. Uh and so with these, then usually we try conservative treatment first and would then consider surgery if they're not improving. So we're happy to see these patients. There's just a huge variation in symptoms in patients that have a partial tear. Some have minimal symptoms, some have severe symptoms, Some tend to progress over time, Some tend to get better over time. So then we get questions from patients with this impingement bursitis, tendinitis, saying, well should I really go to physical therapy? You know, I had a cortisone injection, I think I'm gonna feel better. And why does physical therapy work? Well, it does work. Um And yes we do recommend physical therapy for all of these patients. And the reason why physical therapy works is um there is this impingement component meaning of pinching or tight area. And the theory is that if this is the a crony in this is the versa, this is the rotator cuff tendon In many of these tendonitis patients this space is just too tight and that's why when they raise their arm up or twist their shoulder they get increased pain. So with physical therapy the therapists work on scapular stabilization and this a chromium is part of their shoulder blades so that can bring the chromium up and back. So it basically decompress is this sub microbial space. And then the physical therapist will also strengthen the lower rotator cuff muscles which have um this type of vector. Okay. And was strengthening of the lower rotator cuff muscles, it will pull the human head down. So with physical therapy they have a mechanical way of trying to increase the space for the rotator cuff and basically take some of the pressure off of it which helps with pain. Okay. And so I know I was talking about with full thickness terrors. You should definitely have them. See an orthopedic surgeon? Well not always. So I'm really only talking about with say acute symptomatic full thickness tears because there are some patients that have asymptomatic full thickness tears. Um So this is a study looking at Um rotator cuff tears being an incidental emery finding. And in this study there were asymptomatic full thickness tears in these different age groups. And the incidents of this increases with age. So for example, in patients who are 50-59 there was a 13 in incidents of full thickness rotator cuff tearing. That was a symptomatic, and then people who are over 80, there was a 51 incidence, so MRI might show a full thickness tear but um that but the patient might not be symptomatic from that. Okay, so the main the main goal for for say primary care physicians um in uh with respect to this rotator cuff pathology is to identify those who have rotator cuff tears uh and pathology but to just really refer to us in cases in which you think that they have an acute injury and they have weakness that is not improving with physical therapy and they potentially have a symptomatic and or acute full thickness tear. Uh And those are patients also where you can consider obtaining an MRI earlier rather than later. Okay, so what what are the benefits of sabah chromium injections in rotator cuff disease? Well um this is a review article from 2003 showing that there might just be a small benefit for sub microbial injection and rotator cuff disease over placebo at four weeks. Um But I would say that it is difficult to pull some of this data because their variations. And how are these patients diagnosed as it would just physical exam, ultrasound MRI there are different types of injection cocktails with cortisone that are that are performed. Um And then injection accuracy was ultrasound used to guide these injections or not? Um But I would say in terms of summary overall a lot of patients do get some relief temporarily or permanently with an injection if they don't have a full thickness tear. So in my practice I would usually try one maybe two injections of cortisone sub chrome really. In people with um rotator cuff tendinitis and say a a partial partial rotator cuff tear. But usually I don't do more than two injections total and I'll explain why. Okay so if you start to do too many cortisone injections in the shoulder and around the rotator cuff you can run into problems. So this study showed that patients with greater than a report before steroid injections had worse outcomes after surgery for large two massive rotator cuff tears. Um This study showed that patients with two or more sub chromium injections in the year prior to surgery for a rotator cuff repair were more likely to have revision surgery. And this study showed that there was a higher infection rate with rotator cuff repair surgery in patients who had a cortisone injection within one month of surgery. So what I do in my practice is I limit them usually the to total but definitely two per year. And then we counsel patients to not have a cortisone injection in the shoulder within one month of shoulder surgery mm. Okay so um the last case this is a 30 year old right hand dominant male who fell off his by three months ago and injured his right shoulder. He does not believe that it dislocated but he can't get back to the climbing gym he has and her shoulder pain also some clicking. He really only feels the pain if he moves his shoulder quickly in certain directions and it does not wake him up from sleep at night on physical exam has no atrophy, no bony deformity. And he's tender over the long head of biceps tendon. So that's entirely non tender over his A. C. Joint and his active range of motion of his right shoulder is intact. But he does have a little bit of pain at the end of full flexion. So when he gets his arm all the way to the top, no rotator cuff weakness and he has a positive O'brian's test. Okay so how would you treat this patient? So with this patient I'm thinking that he might have a labrum tear which we'll get to and usually with labor and terrors. We start first with physical therapy injections don't really help people with labor and terror so we shy away from injections. So the labrum is deep in the joint. I always explain it to patients. It's like an O ring bumper around the socket. And it also does help stabilize the human head on the glenn Oid. And this is uh this is looking at the labrum head on. So this is as if I took the human head away and then I'm looking at the glen oid and see this, this soaring bumper that goes all the way around that has the biceps attachment here, that's the labrum. So O'brian's test is really helpful for diagnosis of a labrum tear. This is my primary care sports medicine colleague dr center doing an o'brian's test on the patient. But you want to have the arm ford flex to 90 degrees the elbow extended and then you add up the arm a little bit and you make sure that the that the patient is thumb down. Um and you can just have them hold the arm there and and just say don't let me push your arm down or push up on my arm. And then you want to repeat it with the thumb up, which you'll see at the end. And if the patient has a lot more pain with this, testing with the thumb down, then that's suggestive of a labrum tear. Or slap terror. So here she is, turning the patient more to palm up or thumbs up and then if they have less pain with that again, that's suggestive of a labrum tear. Okay, so we often use the term slap tears fairly interchange interchangeably with labrum terror, but all a slap tear is as a specific type of labrum tear. So slap refers to the location um of the labrum where it's torn. So if you have a slap tear, that just means a labrum tear towards the top, so it's superior labrum entered posterior. There are many different types of slap tears, meaning they could be frayed torn off the bone. The tearing could extend through the biceps tendon. Um And so how do you diagnose slap tears or laboring tears? Well the gold standard is MRI arthur graham. You can just get a standard MRI, but if you get an MRI arthur graham, what it does is it pressurize is the shoulder, so it basically makes the labrum float up and away from the socket if there is a terror there, so it makes it more sensitive to pick up a labrum terror if you order an arthur graham. Um So with slap tears or laughter and tears, usually we do try physical therapy first. But then if the patient is just not improving with time, then we do consider surgery. Um And the surgeries vary depending on the exact type of slap tear. But if it's just afraid, we can do a debridement or clean up. If it's torn off the bone, then we can actually do a repair. Um And if the slap tear extends down through this long head of biceps tendon and they have biceps symptoms, we can do a biceps tendon dcis, where we actually take out the unhealthy torn part of the biceps tendon and reattach the biceps tendon at length in a healthy, in a healthy portion. So this is just something I wanted to say. Um but in people over say even 40 or 50, we usually do not consider slap tears as a source of pain, believe it or not. So if you order, say 10 patients or Um say an MRI on 10 patients off the street who are 50 in their shoulder, where they never had pain, probably half of them on the radiology report. It will say slap tear. Um so the natural history of this superior labrum is that it, just after age 40 or 50 will start to separate from the bone. So it's actually an incidental finding most of the time if there's a slap tear on an MRI in somebody over 40 or 50. So we really have to correlate a slap tear with somebody's symptoms in order to say offer surgery for a slap tear. Mhm. Okay. And this is just an example of one of my patients from recently. Um This is an arthroscopic picture. Here's the socket. So the glen oid, this is the labrum. See, it really does look like this white over in bumper. Here's the long head of biceps tendon inserting onto it. And this patient had a tear here where he was symptomatic and the labor was off of the Glenroy bone. And we just minimally invasively last sue uh sutures around the labrum and then we cinch the labrum back down to bone with an anchor like this. So we just recreate normal. It's actually a very satisfying surgery. Okay, And then we'll talk a little bit about more alternative injections. So I've been getting more and more questions throughout my practice recently about platelet rich plasma. Many of my primary care sports medicine colleagues with UCSF perform these injections and so what is it? Well it's just a volume of plasma with platelet count that's greater than what's typical in whole blood. And they're also growth factors that are present in the platelets. And we think that the concentration of these growth factors and platelets can be a powerful biologic biological treatment for some sports medicine problems. So um different activities that that this concoction might um might incite could be Condra genesis. Mesenchymal stem cell proliferation. We also think that PRP might be anti knows deceptive so to help with pain and also anti inflammatory. So how do we prepare it? Well we do a peripheral blood draw on the patient so it's their own blood and then the blood is centrifuge and the platelet and growth factor layer is separated and then the PRP is ready for injection. Now one of the issues with PRP is that not all PRP is the same? Okay. There are many different centrifuges that give you a different formula of PRP. So the main differences are the presence of Lucas sites or white blood cells and also this vibrant architecture. Mhm. And I'll talk about it in a minute but depending on the exact PRP formulation we think that um certain formulations might work better for different different types of pathologies. So then we've been getting a lot of questions also about stem cell treatment. Well what are stem cells? So stem cells are a type of cell that has potential to different differentiate into cartilage, bone tendon and muscle. We think that they might lead to regeneration of tissue and their uh for us from an orthopedic standpoint, mostly found in bone marrow and fat. Okay. But what are limitations of some of these stem cell studies? Well, many of them have no control group. There is also inconsistent reporting of the exact formulation of biologic treatment so similar to PRP it's sort of comparing apples to oranges in the literature. And then there are some inconsistencies with the injection protocols. No. And I always counsel my patients that it's not just that sometimes stem cells might not work but there are actually some safety concerns. So this was a December 2018 New York times article um in which 12 patients were hospitalized due to infections from injection from injected amniotic cord blood cells from Genentech, which is you know, a reputable local Bay Area company. And of these patients, all of them were hospitalized for 4 to 58 days and they tested unused vials um from the same batch and some of them tested positive for E. Coli and other fecal bacteria. So again there might be some safety issues with these with these cells. Um So they're not drugs they don't need FDA approval. They're not regulated, they're not real registries as of as of today. And a lot of the websites rely on testimonials and here's just one other recent but sort of scary study that was in our orthopedic literature, Journal of Bone and Joint Surgery from last year. And it was entitled online direct to consumer advertising of stem cell therapy for musculoskeletal injury and disease. Looking at misinformation. So this study looked at almost 900 practice websites and About 96 of them contained at least one statement of misinformation, with a mean of about five statements of misinformation among these websites. So then you think, well, what if there's a podiatrist or an orthopedic surgeon associated with these clinics or these websites? Are those more? Are those more accurate? Well, it turned out that Um these practices associated with an orthopedic surgeon or podiatrist only provided 22, 22 fewer statements of misinformation than practices without these specialists. So at least for now, we don't offer stem cell injections for orthopedic issues with UCSF. I hope someday we will. But I would just say that my opinion is the technology is still early and there are some potential safety issues associated with stem cells. But Prp we do offer. And how do we discuss this with patients? Well, um we think that PRP really does work from uh kind of from working through an anti inflammatory perspective, there really isn't good evidence yet that these injections are disease modifying. So we don't think that it can really regrow cartilage or say reverse arthritis. And 11 sort of take home point about PRP from the last year is leukocyte poor Prp we think is better injected into joints. So safe for mild knee arthritis we recommend leukocyte poor Prp. But for tendinitis tendon oh sis or for example um for say a partial rotator cuff tear or rotator cuff tendonitis. Then we would actually recommend leukocyte rich Prp. Uh And then you always want to make sure to that if um if say the primary care sports medicine physician is doing a PRP injection for for a certain body part where it requires ultrasound, that they're skilled in ultrasound as well. And we get questions about cost. On average prp the patients do have to pay out of pocket, it's very rarely covered by insurance and it usually costs about $1,000. Okay, so again, um usually these are not not covered by insurance. Once in a while, especially for tennis elbow, we can get them covered because there's some longer term studies for PRP with tennis elbow, but we usually warn patients that they won't be covered by insurance. And I'm just looking forward to the future when we do have more randomized prospective controlled trials with both PRP and with stem cells, where it's very clear exactly what formulations are used in in those studies. Okay, so, so in this talk, these are this is again just a summary of some of the topics that we covered. So the indications for surgical referral for a patient with rotator cuff disease? Well, a lot of patients with rotator cuff disease either don't have symptoms or if they do they do well with conservative treatment okay. Such as physical therapy, anti inflammatories and a cortisone injection. So many people with impingement tendinitis and partial rotator cuff tears do well with conservative treatment. However, if a patient has a full thickness terror, especially if it's traumatic and they have weakness and they failed physical therapy. Those are patients where we want to get an MRI and we would want you to consider an orthopedic referral For adhesive capsule itis. We covered uh potentially doing a cortisone injection fairly early, maybe two injections and then having them go to physical therapy and just telling them that this is something that can take often between 1-3 years to fully resolve. But along the way, if you do have physical therapy and an injection in anti inflammatories that sometimes that can alleviate symptoms and help speed your recovery surgery is a last resort for adhesive capsule itis and is very rare. And then we covered shoulder labrum terrors. How These usually are only symptomatic in people I would say under the age of 50. And we usually try physical therapy first. Usually cortisone injections are not indicated for labor and terrors or slap tears. But surgery is sometimes indicated if physical therapy does not improve the the patient's symptoms. And I just wanted to point out this um this website, you're all welcome to use it. But it's the sports rehab site for U. C. S. F. And you can also give this to patients. But it does have uh these uh demonstration videos and print outs for different physical therapy exercises for different body parts. So for example if you look it up for the knee it'll give physical therapy protocol for, say, patella femoral syndrome. So I found this very helpful for for my patients