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Scott Webb (Host):  Many of us live with chronic shoulder pain and wonder whether or not replacement surgery is an option for us. Joining me today to discuss shoulder replacement surgery and treatment is Board Certified and Fellowship Trained Orthopedic Surgeon, Dr. Patrick Noud. This is McLaren’s In Good Health, a podcast from McLaren. I’m Scott Webb. So, Dr. Noud, we’re all familiar with joint replacement surgery, usually knee replacements or maybe even hips. But our listeners may not be aware that although they are less common, shoulder replacements are another type of joint replacement. So, tell us a little bit about why someone would need shoulder replacement surgery and maybe what are the symptoms they might be experiencing.

Patrick Noud, MD (Guest):  There are actually two types of shoulder replacement that exist. There’s anatomic shoulder replacement which really is discussing taking the ball of the shoulder joint and what we consider the socket, though it’s not truly a socket and replacing both those pieces of the ball and the socket joint in the same way in which you had them before. And the main reason why somebody would have a shoulder replacement of that manner is for run of the mill osteoarthritis or osteoarthritis as a result of a trauma from previous or as a result of a fracture that has now led to an arthritic pathway. Overall, that is probably about 50% of the time that we do shoulder replacement. And the symptoms regarding that are usually slow and insidious meaning people start to lose motion over the course of several years. They start to have a lot more of the cracking and popping that we’re sort of used to hearing in our joints as we get older and then as we get stiffer and become louder, I guess in our joints; we start to have more and more pain and that pain can be really anywhere. It could be on the side of the arm, down the arm, up into the shoulder, up into the neck, but largely between the base of your neck and the distal portion of the upper arm is where the vast majority of the symptoms will lie. So, that’s anatomic shoulder replacement.

The second type of shoulder replacement is a reverse shoulder replacement which sounds odd, but it’s exactly what it sounds like. So, instead of replacing a ball and a socket with a ball and a socket, you would replace a ball and a socket with a socket and a ball. And it’s a mechanical switch or a reverse of the components. But the result of that is a stabilized shoulder in the setting of someone in which their shoulder has destabilized for different reasons, either because they have a massive chronic rotator cuff tear that has left their shoulder essentially unstable without a stable fulcrum to work with. Or because of the fact that they’ve had a series of events that has lost the soft tissue envelope about the shoulder that would make the shoulder function as normal.

Host:  I think I have the osteoarthritis one. That’s the one that I have for sure being 51 and so I wanted to ask you about who typically needs these procedures. Is it older adults, athletes? Is there a “typical” shoulder replacement patient?

Dr. Noud:  I guess there is a typical shoulder replacement patient. I’ll answer a couple of questions with that. One is, who needs a shoulder replacement. I would sure argue that nobody needs a shoulder replacement. I would say that a shoulder replacement is a procedure to improve quality of life and so, somebody would like to or wish to have a shoulder replacement if their quality of life has gotten to the point where they aren’t able to do things that they would normally like to do. And so it would preserve that quality of life. I’m always safe to say to all my patients that you never have to have a surgery such as this meaning, nobody has ever died from an arthritic shoulder, but you can certainly be miserable. And so that’s what this is for.

But when it comes down to a typical patient that would require this; we are talking about the older patients. Generally speaking, we’re talking about patients that we’d like to be in the late 50s, generally at the earliest. You are getting into the 60s and 70s are sort of the wheelhouse of these procedures. And when you are getting up into reverse shoulder replacement, for these other sort of chronic soft tissue problems such as rotator cuff tear; we see patients even into their 80s and quite honestly, into their 90s that qualify and choose to have these procedures for pain relief and functional improvement processes.

Now, I wish everybody would be able to live until their late 50s into their 60s to have a shoulder replacement but there are people that have a bad problem and it’s much earlier in their life that require something like this to happen. So, it can be done for somebody in their 40s, even in their 30s. but it requires a lot of give and take and discussion and education between the surgeon and the patient because the younger you are, the more demand you are, the heavier you are going to treat – you’re going to work with that shoulder and thereby the quicker you may wear that shoulder out and there are complications and consequences to wearing a should out and trying to do something like a revision or a secondary shoulder replacement. So, those are all discussions that need to happen between the doctor and the patient.

Host:  Yeah, it does sound like there’s a lot to discuss there. Are there certain conditions, activities or injuries that may lead to shoulder replacements? Are there certain sports perhaps baseball or golf that increase the likelihood of shoulder replacement?

Dr. Noud:  Literature on that is pretty sparse actually. You might think that a major league pitcher that has thrown their arm out multiple times or the golfer and the rotations or the tennis player with the torque with the overhead serve and those sorts of things would come out as being a more likely candidate or at least have caused that damage to their joints, but the literature hasn’t really played that out. What I will say, there’s a lot of correlation between age and injury. So, if you were an athlete or otherwise had an accident that caused a dislocation of the shoulder back when you were 20 or 30 years old or if you’ve had surgery on that shoulder because of a chronic problem; we know that people that have had traumas that require surgeries oftentimes the uncommon pathway of both the injury and the surgery to correct the problem in the short term, may lead to an osteoarthritic pathway or arthritic pathway of some sort. Similar to that though, when you talk about sports or an athletic situation, oftentimes, the body is an amazing thing. As you utilize the body or you stress the body, the body reacts by gaining strength whether that be the bones getting stronger, whether that be the joints and the muscles surrounding the joints taking the impact and the force away from the wear and tear aspect but we come to find at least so far that we don’t see the correlation strongly between sports.

I will put one caveat out there and tell you that in my former life when I did a lot of professional sports physicals for the National Football League back out in San Diego, California, we saw a lot of former NFL players and I will tell you, all their shoulders are complete junk. They beat themselves up pretty badly but it’s not just their shoulders, it’s their knees, their hips, their ankles. It’s essentially everywhere the body can be hit; those guys get beaten up pretty badly. The last thing I would say though is realistically osteoarthritis has a large genetic component. So, I think if you look at your history in your family and the history in family members around you, you’ll have a much better idea of how likely it is that you may have arthritic joints going forward and I do like to tell my patients that when you are a baby, and they drive you off the lot like you are a new car, you have a certain or new tire on your car and we just don’t know whether the tire they put on that car is an entry level Bridgestone or a high end Michelin tire and how many thousands of miles you are going to get off that tire.

But that’s the genetic component of this. Some people are blessed with intellect, some people are blessed with strength and some people are blessed with greater or poorer joints that will last the test of time.

Host:  So much to absorb there and unpack but it’s interesting that the literature doesn’t support our instincts which are that sports are absolutely the culprit in shoulder replacement. You talked about the actual surgery and the two different types. Are there other factors to consider? Is one more standard than the other? Do you have a preference of one or the other?

Dr. Noud:  Yeah, well I think that you would always like to restore anatomy if possible. So, I have many patients that I have done both an anatomic shoulder replacement on one arm and then a reverse shoulder replacement on the other arm. And I would say it’s about fifty/fifty whether people like their more anatomic shoulder replacement or the reverse shoulder replacement and it’s partially because the vast majority of people that have shoulder replacement are trying to have pain relief. And pain relief is very consistent with both procedures. The joint becomes a little bit less complex when you reverse it per se, when you stabilize the joint. The consequence of that is two-fold. If I could walk backwards just a minute, the shoulder joint itself is not what you think of as a ball and socket joint like the hip. The ball of the hip is surrounded by a deep cup that provides it a tremendous amount of stability. But the consequence of providing tremendous amount of stability is that the range of motion of the hip is limited. The shoulder, on the other hand is much akin to a golf ball on a tee. And if you have a golf ball on a tee, you know that a golf ball is a bigger ball and the tee is a very small platform. If you take that joint and you turn it 90 degrees, you essentially have your shoulder joint. The consequence of that is, is that the shoulder can rotate in six degrees of freedom without impinging on any soft tissue or structures and the ligaments that surround the joint are loose. Almost like bungee cords that allow a lot of stretch and very little limitation of motion. This is why you can see contortionists do amazing things with their shoulders.

The consequence of that is you essentially sacrifice stability. So, when you have an anatomic shoulder replacement and you give back the normal stability that exists in the shoulder, your potential for improvement in motion and thereby your ability to have a normal feeling and operating shoulder is a bit higher than it would be on a reverse shoulder replacement. Because when we reverse the shoulder, it’s for the purposes of oftentimes of instability and so the point of that procedure is to stabilize the shoulder and because in the act of stabilizing the shoulder, we essentially make the shoulder joint into a hip like joint which sacrifices some range of motion for stability. It can provide tremendous pain relief but it will and can limit motion compared to a well done anatomic shoulder replacement.

Host:  You have a great way of explaining things, you analogies, the golf ball on a tee. I mean I can really picture what you’re saying, and it helps me to better understand why we do have so much range of motion in our shoulders and not nearly as much in our hips at all. It actually really makes sense to me now. So, what about recovery? Can patients expect to return to all the activities they enjoyed before the procedure? Are they ever 100% again?

Dr. Noud:  I don’t know that I would ever tell somebody that they would be 100% after shoulder replacement. I would never promise somebody that I’d give them the shoulder they had when they were 20 or 30 years old. I think that that time has likely passed. But people can get back to most everything that they want to do. Now remember, 95 if not more percent of the people that I operate on for a shoulder replacement will be in their late 50s or later and so those people will get back to the vast majority of the things that they do on a regular basis. Now, I’d let them come back to racket sports, I’d let them go back to golf, any sort of aerobic activity that they’d like to do but there are a few caveats that I tell them, not that I don’t allow them to do but that I wouldn’t recommend them go back to. And the two in particular would be lifting heavy weights for the purpose of lifting heavy weights. We’re talking about the people that go into the gym and at 60 years old are still trying to bench press 250 pounds and use military bars a way to build bulk and strength and I sort of tell those people that if you are still able to do that now, despite your shoulder pain or your limitations; continue to do that and when you are done doing that, because you are so miserable with your shoulder that you’ve given it up, then I can give you back a shoulder that is pain free and functions better, but I wouldn’t like you to go back to that activity.

The second person is a person that has been doing a hard manual job. So, the construction worker that torques sort of at the end of his career or somebody that let’s say is working the line at General Motors and does heavy manual jobs and repetitive lifting. And those types of people, they can go back to those jobs, but they will wear and tear these shoulders a lot quicker than the average person. The difference between your own shoulder and a metal shoulder or a metal and plastic bearing surface shoulder is that your shoulder is alive and so as you put more stress on it, it reacts, and it attempts to adapt to the situations in which you put it in. A metal and plastic shoulder does not and so consider the fact that its tread can wear at a linear rate and its bearing surface can loosen at a rate I guess I would say commiserate with the stress you place upon it.

So, you have to make a choice and your doctor’s not going to babysit you. But if you are looking to have a surgery and have that surgery be successful, and hopefully be the only surgery that you need for the rest of your life, you need to treat this, and I have one more analogy, like a sports car that you’ve always wanted. And you could treat a sports car like you always wanted by saying I have this sports car and I’m going to drive it 100 miles per hour on every back country road or you could say I have a sports car and I’m going to keep it in a heated garage and polish it and only give my wife or husband a ride in it when it’s nice and sunny and five years later, it’s only going to have 5000 miles on it so it’s still going to purr like a kitten. You are still going to be proud whenever you get into it. Or if you beat it up over five years, you had a great time but it’s no longer the car you wanted.

Host:  So, lastly here Doctor, what advice can you share for our listeners who may be experiencing shoulder pain and wondering if shoulder replacement is the best option for them?

Dr. Noud:  The honest truth is shoulder replacement surgery is sort of a small niche in the shoulder world as we age and very commonly, I believe that people think that every pain that they have is likely related to arthritis in their shoulder. I think that that’s perpetuated by the fact that when somebody has pain in their shoulder, they get an x-ray and a radiologist reads there is some arthritis in the shoulder, and I think anybody over 35 will have a little bit of that. And so they are told that by whomever it is that took the x-ray and hey believe that that must be their problem and they live with it. The truth is that rotator cuff problems exist far more commonly than arthritic shoulder conditions exist.

And so as you age, the real question is do you have a rotator cuff problem and if you do, what do we do about that? And that would be pain that affects you on the lateral side of your arm, certainly raising your arm away from your side, pain that seems to be worse during sleep. I would say those are probably the main symptoms of a rotator cuff problem. When you are starting to question whether you may have an arthritic problem, you’re probably thinking about how loud your should sounds and you’re probably thinking about how you’ve become less and less flexible over years. So, these conditions oftentimes will sort of sneak up on you over time, these arthritic conditions. And if you’ve really felt like over the course of many years you’ve had an ache that may be or may not be associated with increased activity, pain at night, cracking and popping, slowly loosing range of motion; these are probably signs of an arthritic shoulder condition.

That being said, it’s not you to diagnose the arthritic shoulder condition or whatever you shoulder condition is. If you have enough pain in your shoulder and if that pain is affecting you at night and if you are having difficulty lifting your arm; then it’s worth being seen and it’s worth making sure that you have an idea of what your problem is and what your options may be. And at least in my office, I hope my patients feel the same way, but I never tell somebody you need surgery. I tell them this is what you might need to happen in order to get out of pain or be out of disability with your shoulder. But it’s ultimately your choice and whenever I tell anybody what your choices are, the first choice I always tell them is if you don’t like my other choices, you just live with it and you walk out of this room. That’s not wrong. But I think people are scared to see a doctor about their shoulder because if you know anybody that’s had shoulder surgery, you will find that those people that talk about it are the people that had some discomfort recovering from that or maybe didn’t do as well as the person next to you.

But I will tell you that this is a very successful procedure. It’s my favorite thing to do. It’s kind of my bailey wicket if you will. And I believe that people think that shoulder replacement is a less common and more complex and more difficult process to recover from whereas I would say, it is one of the most successful and easy recovery processes with the highest satisfaction of any surgery that I do. So, if you’re concerned about that, certainly don’t be scared about getting it checked out and know that nobody can pressure you into doing something you don’t want to do but your options are on the table.

Host:  Yeah, absolutely and as we’ve talked about today, you’ve mentioned it really comes back to quality of life and that nobody “needs” necessarily shoulder replacement surgery. But it is an option. There are a couple of different ways to do that and with doctors like you who can explain things and use analogies and let us know what our options are, people should be in good hands. So, Doctor, thanks so much for your expertise today and your time and breaking all this down. You’ve really kind of helped me and I’m sure you’ve helped the listeners as well to kind of picture how things work and know what our options are. And stay well.

To learn more about Dr. Noud or to submit a question, visit www.mclaren.org/noud. And if you enjoyed this podcast, please share it on your social channels and check out our entire podcast library for other topics of interest to you. This is McLaren’s In Good Health, the podcast from McLaren. I’m Scott Webb. Stay well.