Shoulder disorders affect nearly every American at some point in their lives. Fortunately, most of these problems can be treated well nonsurgically. For others, surgical treatment is a viable option.
Shoulder disorders for those 40 and older can usually be broken into one of three diagnoses: stiffness (frozen shoulder), arthritis and rotator disease. These shoulder problems make up more than 90 percent of diagnoses. These common diagnoses happen regularly and it is rare for a person to have multiple diagnoses within the same joint.
Whether the shoulder problem is a fracture, ligament tear, tendon tear or arthritis, up to 90 percent of these problems can be treated with methods such as rest, immobilization, medication and therapy programs.
When surgery is considered, a concrete diagnosis is essential. That’s because a diagnosis that was previously unknown, is unlikely to be discovered during the operation.
In 2018, quality imaging options like well-performed X-rays, CT and MRI scans are excellent tools to help us identify whether a mechanical cause may be associated with a patient’s clinical symptoms.
It is important to keep in mind, though, that pain is a symptom and it is often non-specific. It would be ideal if, as surgeons, we could “erase or remove the pain.” Unfortunately, that is not the case. Pain may be caused by one or multiple sources: mechanical, neurologic, vascular, chemical, psychosocial, etc.
For pain caused by mechanical sources, orthopedic surgeons can help a great deal, but that is not always the case. Orthopedic surgery for nonmechanical problems is ineffective. New tires will not help a driver who is asleep. Filling a car with gas will not address a dead battery. Sometimes even with mechanical problems, the act of surgically addressing the problem may leave some people with residual pain that is not well addressed with further surgical intervention or medications.
During my career, I have been fascinated by the psychosocial and emotionally-related factors that go into a patient’s decision to have surgery. For example, the offer of surgery can be validating to a patient. Suddenly, their pain profile or clinical history is being considered “thoughtfully enough” that the surgeon offers surgery. But that slope is slippery. Failure of all other options is rarely, if ever, a good reason for surgery. In fact, failure of other nonsurgical treatments only proves that treatments are capable of failing for the patient.
In order for surgery to be as successful as possible, the patient’s clinical presentation must match their X-ray, CT and MRI imaging and the patient must be physically, mentally and emotionally fit enough to undergo surgical intervention with a reasonable chance of success. The diagnosis and treatment plan need to “make sense.” Straying from fundamentals or undisciplined thought processes can get us into more trouble than anything else.
Surgery is performed on patients, not radiographic studies. In musculoskeletal medicine, we are still sorting out some of the findings that we see in radiographic studies. Often, normal, age-related changes in radiographic studies are blamed for a joint’s pain. Unfortunately, it is not that simple, so it is best to proceed cautiously when working through a radiographic (MRI/CT) report. That’s because the “money” is in matching a patient’s presenting complaints with the test results.
If you think of overall wellness as a three-legged stool, physical, mental and emotional health each make up one of the stool’s legs. When all these legs are on sound footing, a patient has a greater chance of responding positively to any musculoskeletal treatment, nonoperative or operative. The more balanced that stool sits, the better a chance of recovery a person has if they sustain an injury to one of those proverbial legs.
Dr. Edward Fehringer is an orthopedic surgeon with Columbus Orthopedic & Sports Medicine Clinic.