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Bill Klaproth (Host): Your shoulders are the most moveable joints in your body, but that mobility comes with a price and may lead to shoulder disorders resulting in pain. Here to talk with us about shoulder disorders and how to treat them, is Dr. Edward Fehringer an orthopedic surgeon at Columbus Community Hospital. Dr. Fehringer, thank you for your time. So, what are the most common shoulder disorders you treat?

Edward Fehringer, MD (Guest): The three most common are shoulder stiffness in the form of what is often called frozen shoulder, rotator cuff tears and arthritis. Those three diagnoses probably constitute 90 plus percent of the shoulder disorders with which patients present to me in the clinic format if they haven’t been proceeded by any sort of trauma to the shoulder.

Bill: So, what you are talking about there is general wear and tear injury to the shoulder?

Dr. Fehringer: Well, shoulder stiffness most of the time, doesn’t come from wear and tear. It’s not a real well understood phenomenon in terms of what occurs on a cellular level or the etiology or what the cause of it is. But, typically the joint gets inflamed without any trauma. The shoulder slowly and progressively gets stiffer because the capsular tissues that sort of connect the ball to socket thicken and get tighter and that’s all a very painful process and eventually, that shoulder tissue will sort of I don’t want to say thin back out, but the tissue sort of becomes more elastic again, but unfortunately, that can take 12 to 24 months for it to occur, those three stages. Arthritis is a wear and tear phenomenon of the joint surfaces, the cartilage joint surfaces and rotator cuff disease can be sort of a wear and tear phenomenon. It is really more of an aging related phenomenon. As we age, unfortunately, our rotator cuff tendons get a little thinner, weaker and more susceptible to injury.

Bill: Well those are really good distinctions and thanks for explaining that to us. So, for someone with shoulder pain, when is it time to see the doctor?

Dr. Fehringer: Oh, probably the hallmark of a lot of shoulder pain is night pain, difficulty sleeping, with or without any trauma as I mentioned. Those three diagnoses can come on and so that’s typically what affects people and also when it starts to affect activities of daily living like simply their ability to do things recreationally becomes compromised whether it’s playing golf to being able to do simple activities around the house or even at their place of employment.

Bill: So, how do you diagnose someone with a shoulder disorder, someone experiencing shoulder pain?

Dr. Fehringer: Sure, their demographics enter into an important part of the history, so the patient’s age and sex and what their activities are during work and outside of work. Those are all really critically important certainly. That is followed by an examination of their shoulder and also their opposite shoulder assuming their opposite shoulder is okay and hasn’t been injured or traumatized in any way. And typically, we can start based on whether or not it is indicated with the history and exam; we can get plain x-rays and x-rays help us, as long as they are well done, they can actually help us determine a lot with respect to the bones and cartilage surfaces. And then if we take another step beyond that, ultimately, at times patients will be required to undergo an MRI scan to evaluate their soft tissues in more detail.

Bill: So, then you get a really close look at exactly what you need to do and speaking of that treatment, Dr. Fehringer, can you tell us about the protocol? Where do you generally start?

Dr. Fehringer: History number one. That’s the most important thing and oftentimes, we can get a pretty good idea based on the patient’s history as to what their diagnosis is before we even examined or obtained any sort of x-ray studies or MRI studies.

Bill: And when it comes to treatment Dr. Fehringer, where do you start with treatment for someone with shoulder pain?

Dr. Fehringer: So, number one thing in terms of treatment is the diagnosis first. Before we initiate treatment, we have to have a diagnosis or at least a differential diagnosis meaning it’s one of a few different potential diagnoses. Generally, if patient has a normal set of x-rays, and what I mean by that is there are no fractures. There are no dislocations and the ball and socket cartilage surfaces appear smooth; then we would generally assess for their range of motion on examination, their passive range of motion meaning the limits to which I can take that joint or the opposite arm can take that joint. And if their passive motion is restricted with normal x-rays; by and large they have shoulder stiffness 90% of the time. And so, our focus is simply on stretching that tissue back out. If for any reason, their cartilage surfaces are irregular and clearly have arthritis; then the focus becomes trying to maintain the sphericity or the roundness of the ball as long as possible and the general flexibility of the ball and if that irregularity is too extensive that motion is not able to be maintained or the sphericity has become lost; then it becomes just treatment with medications and trying to keep as much motion as possible, sometimes using cortisone injections and then ultimately joint replacement. If they have normal x-rays, they have full motion passively, but they still have pain; we would go to the soft tissue studies in the form of MRI scans to assess the rotator cuff. So, that’s kind of the stepwise process and that constitutes at least 90% of patients that present without trauma, but prolonged shoulder pain to at least get them started with a diagnosis and treatment.

Bill: So, when you talk about that stretching out process, is that physical therapy you are talking about, that’s where you send them first?

Dr. Fehringer: Exactly. They are taught exercises to primarily warm up the joint and stretch those tissues out. Therapists can help teach them a home program and or have them return two to three, four times a week to help stretch that tissue.

Bill: And generally, physical therapy is very successful, is that right?

Dr. Fehringer: Absolutely. Physical therapy is very successful, probably 90% of the patients that present to see me in the clinic don’t need any surgeries, so that can be reassuring to the patient and sometimes simply having some knowledge and all the complexity of what goes into shoulder diagnoses and treatment can be very – it can really be helpful in alleviating anxiety about the many disorders out there and potential problems and the fear of surgery because most of these things can be treated without surgery in the form of physical therapy, home programs, injections, pills, those sorts of things.

Bill: And that is such good news and you did mention surgery. How has shoulder surgery progressed?

Dr. Fehringer: Well, I don’t think that the diagnoses have changed at all, but our ability to come to those diagnoses has improved to a degree. Unfortunately, as in so many other areas; it still comes back to the foundation or the basics of establishing that diagnosis before we institute treatment and as happens so often, as human beings, we are enamored with the latest, the greatest. And the fact of the matter is, all the improved technology and whatnot, doesn’t really change the diagnosis, nor the biology, nor the anatomy, nor any of those sorts of things and so it’s easy to get distracted and jump into the treatment before we even have a crisp diagnosis and probably that’s the greatest problem that we see, despite the improved technology. So, as x-rays get better and the education gets better and our understanding gets better, that’s great, but then when we make that leap to MRI scans; it’s great, the images are pretty, they look very neat. They allow us to see things that we otherwise couldn’t see on x-ray. Unfortunately, it brings about a whole new sort of level of complexity. We have to actually understand what we are looking at when we look at those new images and what findings on that MRI scan are associated with aging, what are associated with some of the comorbidities that the patient has, whether they are a smoker or use alcohol of have poor nutrition. So, the difficult part in making that; it’s great that the diagnostic imaging is improving; unfortunately, we have to improve with them and understand exactly – I shouldn’t say unfortunately, but we have to get better too at understanding what those studies are actually showing us and how we can actually tie it back to the patient’s history and examination. It’s like everything in life, I mean certainly all the apps and internet stuff is great, but it also comes with a price that we all are faced with every time we turn on a computer or look at our smartphone.

Bill: So, true. So, there is certainly a lot of information you have to filter through when making that diagnosis and what are the proper treatment channels. Well Dr. Fehringer, thank you so much for your time today. we appreciate it and to learn more about shoulder disorders and treatment, head over to www.columbushosp.org, that’s www.columbushosp.org. This is Columbus Community Hospital Health Cast from Columbus Community Hospital. I’m Bill Klaproth. Thanks for listening.