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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme no. 7 - Shoulders
RADIO 4
TUESDAY 13/03/07 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
ANGUS WALLACE
STEVE LONGWORTH
TIM BUNKER
STEVE COPELAND
PRODUCER:
DEBORAH COHEN
NOT CHECKED AS BROADCAST
CLIP
Jonny Wilkinson's return to English rugby will have to wait for at least another couple of weeks. Wilkinson, who hasn't played since his World Cup final heroics in Australia, was due to make his comeback for Newcastle on Sunday but a shoulder injury has forced him out of that match and England's ....
PORTER
That was December 2003, since when Jonny's just managed just three appearances for England. And further injury meant he missed last Sunday's surprise victory over France - although it was his hamstring, rather than shoulder, that let him down that time.
Not that you need to submit your body to the rigours of international rugby to hurt your shoulder.
CLIP
My name is Jill Douce. I have arthritis in several joints including my shoulders. I recently, last October, had an operation on my right shoulder. I've been having problems with my shoulders for some years but about 10 years ago I pruned a rose with some long handled pruners and really upset it and it's been giving me quite a lot of trouble ever since. I couldn't do my bra strap, quite often reaching to put tights on was difficult.
PORTER
Later on I'll be finding out how resurfacing helped fix that lady's arthritic joint, and meeting the surgeon who developed the procedure.
And I'll be joining a group of orthopaedic surgeons learning about the latest developments in the surgical treatment of frozen shoulder - a common cause of pain and stiffness, particularly in middle age.
My guest today is Angus Wallace, he's professor of orthopaedic and accident surgery at Queen's Medical Centre in Nottingham.
Angus, before discussing what can go wrong with a shoulder, perhaps we should start by explaining some of the key characteristics of the joint. It's a ball and socket type joint but very different from the more familiar ball and socket set up in the hip.
WALLACE
Yes, the shoulder is one of the most mobile joints in the body. In order to be able to get your hand behind your back and behind your head you've got to be able to move it through a huge range of movement - 120 degrees going up and going out 90, in 90 - and you can only do that if you have a very shallow socket, a large ball and something to hold it together which is the shoulder ligaments and they're very important.
PORTER
So if you didn't have the shoulder ligaments the arm would literally fall off, it's not held in the socket is it.
WALLACE
That's right and the ligaments need additional support from muscles called rotator cuff muscles that are around that ball and holding that ball centrally in the socket.
PORTER
What about the forces on the shoulder? Of course one of the problems with the hip and knee is it's weight bearing and they're prone to all sorts of forces, does the shoulder get an easier time though?
WALLACE
Slightly easier but on studies looking at forces going through the muscles around the shoulder you're talking about putting full body weight through some of the tendons, full body weight - 70 kilograms, for some of us a little bit heavier, 100 kilograms - and that's a significant force going through what are quite small tendons.
PORTER
What about the side that you get the problems - presumably we're more likely to see problems in the dominant side, if you're right handed that's where you're going to get your shoulder trouble?
WALLACE
You would think that and it's interesting it's close to half and half, slightly more dominant side but only marginally. And we do see a lot of trouble with the non-dominant shoulder as well.
PORTER
Well shoulder problems are common in general practice but most doctors readily admit they are more confident diagnosing hip and knee symptoms. Steve Longworth is a GP with a special interest in musculoskeletal medicine and I asked him how well he thought the shoulder is managed in general practice.
LONGWORTH
Well I suspect moderately so, in that something like perhaps one in three people who come to see their GP will get an anti-inflammatory for their shoulder problem, maybe 1 in 10 get an injection. But one of the great difficulties is actually deciding precisely what this shoulder pain is that someone's come along with. One of the difficulties with all musculoskeletal problems in general practice is that the whole problem of teaching doctors how to diagnose bone and joint problems is not given tremendous emphasis at undergraduate and postgraduate level, so very often one finds that people's knowledge in this particular area is not in depth and so they tend to speak in broad brush strokes about diagnoses. A particular sort of black hole into which many diagnoses go is the frozen shoulder which tends to be the label that lots of people come up with for just about any kind of shoulder pain. And while a substantial number of people do have what is actually a frozen shoulder, there's lots of other shoulder problems, although in practice - certainly in general practice - maybe just two or three conditions account for perhaps 70% of the problems that we see.
PORTER
Well let's have a look at those - let's start with frozen shoulder - what is it?
LONGWORTH
It's a common condition that occurs in middle aged people - people like me, people between 40 and 60 years of age. It comes on gradually with pain and restriction and the thing that you find when you examine them is that not only is it painful to move the shoulder about but it seems to be getting somewhat stuck and this is where the name frozen shoulder comes from. And the frozen shoulder is classically said to go through three phases: that's freezing, frozen and thawing out. So it's said that a frozen shoulder eventually if you do nothing and just wait gets better in about 18 months, perhaps a bit longer, although you might be left with a little bit of restriction.
PORTER
I suppose the problem with putting somebody into that diagnostic category, if they haven't got a frozen shoulder, is you're missing something that's perhaps more treatable. What else might it be?
LONGWORTH
Yes, in fact, certainly in my experience of dealing with shoulder problems, the commonest thing that causes shoulder pain is what's known as - well we can put in the category of what we call impingement. And what this means is stuff getting caught in the tight space inside the top of the shoulder. So if you think about the very top of the shoulder bone and the arm bone that dangles below it in this tight spot there's a hoody - it's actually the tendons that move the shoulder around - but if you think of it as being a hood around the top of the arm bone and just above that hood there's a little bag of lubricating fluid, it's these two structures that tend to get either inflamed or in some cases even a bit torn that causes most of the shoulder pain that we actually see in general practice.
PORTER
So what can I ask my patient and what signs and symptoms can I list actually in the consulting room that would help me differentiate between something like a frozen shoulder and impingement symptoms?
LONGWORTH
This is one of the difficulties - if you ask the patient where their pain is generally they grab the top of the upper arm, in fact many people come along saying it's my arm, rather than it's my shoulder. But they do what they call the grab sign - which is to hold the upper arm in the opposite hand and rub up and down and say the pain's here. And the difficulty is that both impingement problems and frozen shoulder give you pain in exactly the same place. So sadly the location of the pain doesn't help you to differentiate between these two very common problems.
PORTER
If we GPs aren't that good at making correct diagnosis early on in shoulder problems can we get help from physiotherapists - is there any evidence that they have more expertise in this area?
LONGWORTH
I've got many physiotherapy colleagues who I'm more than happy to refer patients to when I'm struggling to make a diagnosis, they're very good at recognising such conditions as instability in the shoulder and also recognising a phenomenon called muscle imbalance, which is essentially where the muscles at the front of the body and the back of the body are not balanced up together and as a consequence it makes you more prone to the problem of impingement - nut crackering the stuff in the tight space in the top of the shoulder.
PORTER
Dr Steve Longworth talking to me earlier from our studio in Leicester. You are listening to Case Notes, I'm Dr Mark Porter and I am discussing shoulder problems with my guest orthopaedic surgeon Angus Wallace.
Angus, let's start with the impingement that Steve mentioned there, who tends to get it and which tests can we do to differentiate it from that other common problem - the frozen shoulder?
WALLACE
People between the age of 40 and 60 typically get an impingement syndrome, often out of the blue and what they notice is an aching pain in the upper arm and when they lift their arm up to shoulder level they suddenly get a severe pain during the lifting of the arm, such that they don't want to life it any further. In fact they can usually get above the pain, so you've got what has been called in the past a painful arc halfway up.
PORTER
So they can move their arm out from their side and that's okay but once they get into the sort of middle part of the arc that's when the trouble arises?
WALLACE
Then they have quite significant discomfort and then they can get above it and often can be almost pain free at the top.
PORTER
And practically what might - what sort of movements might they do in their everyday life where they'll notice they have a problem?
WALLACE
Oh lifting a biscuit tin off a shelf or lifting tins of food off shelves...
PORTER
Where their arm is extended and out.
WALLACE
They're struggling to get up above shoulder level and they don't like doing that. Of course some people compensate by getting a footstool in order to not have to stretch up.
PORTER
Assuming you make the diagnosis of impingement syndrome - and I want to come back to trauma in a minute, the role of trauma in this, if you've injured yourself - but assuming there's been no injury, how should the problem be tackled?
WALLACE
Well first of all we know that simple non-steroidal anti-inflammatories, the drugs that you use when you have inflammation, can be very effective and I'm a great advocate if there's no tummy trouble for recommending ibuprofen ...
PORTER
A major tool in general practice Angus.
WALLACE
That helps and can make quite a big difference in the short term. But if it continues over a period of more than a couple of weeks then you really should see if a physiotherapist can help you with it. People can get by with modifying their activities, not lifting their arm above shoulder level, just - not doing as much and often it will just go away by itself. If it stays - a course of physiotherapy, if a short course of physiotherapy doesn't help then you need help.
PORTER
And to see someone like you. And briefly - I don't want to go into the details of what you might do - but I mean would things like injections - are you look at that - is it surgery - surgical intervention?
WALLACE
Well my first step is always an injection into the area where the rotator cuff tendons lie ...
PORTER
Part of the hoody that Steve was talking about.
WALLACE
Yes, I try that once, both as a diagnostic injection and as an injection to help cure the problem. And in 50% of people with an impingement you will find that they settle down with one injection.
PORTER
What about if there's been injury - if somebody's injured themselves and has got this problem - they can't lift their arm up over their shoulder properly?
WALLACE
There's really two groups of people - the younger group with a severe injury, aged between 40 and 60 and these are a worry to me because they're people who may well have torn their rotator cuff, if you don't operate promptly then they can get long term problems and therefore we would like to see them referred up to hospital more quickly, they need an ultrasound scan to identify the tear. Older people can have a rotator cuff problem, with degeneration or a small tear, and then they'll have a minor injury and make it a bit bigger and that's quite common. That is less important, with regard to having prompt treatment.
PORTER
But the combination of that sort of pain and trauma is important. Let's move on to frozen shoulder, briefly, I mean we mentioned we were going to do it last week in the programme, we've inundated with e-mails from people offering all sorts of different interventions which they say can speed it up. Is there any evidence that early intervention at general practice level can make a difference for someone with frozen shoulder?
WALLACE
Well first of all as Steve has pointed out let's get the diagnosis right because everybody's labelled with frozen shoulder. If you can't get your hand up behind your neck then that is an indication you might be developing one. We do a test where the arm is bent to 90 at the elbow, you twist out and if you can't twist out more than 20 degrees then that's a frozen shoulder until proved otherwise. In that case, once you've got to that stage, it's unlikely physiotherapy or alternative therapies are going to make a big difference. I've seen people treated for months and months and months by physiotherapists with no benefit. So that if you've made the diagnosis of frozen shoulder you need, in my opinion, to see somebody who can give you an intraarticular injection and we know that is effective in a group of patients.
PORTER
Well yesterday we joined a group of surgeons on a course at the Royal Devon and Exeter hospitals. They were all there to hear about developments in shoulder surgery including the latest keyhole technique for treating the more severe cases of frozen shoulder. Consultant orthopaedic surgeon Mr Tim Bunker runs the course.
BUNKER
What happens in the shoulder is that scar is laid down and this is what we found out through some studies about 10 years ago, that the cause of the contracted or frozen shoulder is scar tissue which is laid down in the normally elastic tissues that bind the ball to the socket and they literally bind the ball to the socket as though you had steel [indistinct word] in there binding the pair together and that's what we need to release and that's what we release these days through the keyhole surgery.
ACTUALITY
And we're going to start to prep up now. She's - the patient's had a contracted or frozen shoulder for nearly a year now. [Indistinct words]
We know a little bit about it, we know associations with it - we know that there are some associations with people who have scarring in their hands, what's called a Dupuytren's contractor. We know there are associations with people who have diabetes. We know that it occurs in people around the age of 50, indeed the Japanese call it 50 year old shoulder. But we're not entirely sure what triggers it off, whether there's a genetic predisposition or a minor injury or something to actually be the trigger.
ACTUALITY
So she's got a very irritable shoulder. Now the question is why do people get so much pain? When I started to talk about contractors people said well this - it can't be anything like Dupuytren's because Dupuytren's is not painful. I have a feeling that the pain may be due to bleeding in the joint, like you see there - it's quite a bloody joint to start with. And I think it's due [indistinct words] into their shoulders and that's very different of course from Dupuytren's, where they don't have a joint to bleed into. None of us really know what the pain is due to but I have a feeling it may be something to do with that. I think that's why they get jerk pain - jerk pain is not down in any of the textbooks but if you ask anybody with contract or frozen shoulder they'll say that if they have a little jerk it brings tears to the eyes, it's really, really painful.
These days what we do is to do an arthroscopic release, in the old days what we used to do was what's called a manipulation under anaesthetic, where we freed off the scar tissue by literally manipulating the arm under an anaesthetic. It was quite crude, it was effective but took quite a long time to settle down and had some small risks. These days we use keyhole surgery and the idea of that is that it's a little bit more sophisticated, it's a bit more careful with the tissues, the patients get better quicker, they get better better, in other words they get better results than the old manipulations and they tend to improve quite rapidly.
ACTUALITY
Okay, so we're getting a typical appearance here of a frozen shoulder. I'll just bring up the focus and you can see this new blood vessel formation on the biceps there and it's quite striking. Lots of little capillaries running up there, you can see these extraordinary blood vessels which are running - and you can see a little bit of bleeding as well there. So I'm sure that this happens all the time with patients with the contracted shoulders ...
PORTER
The view from Tim Bunker's arthroscope inside the patient's shoulder joint is relayed to a large video screen for all to see. Once the scar tissue is located it's quickly divided using a tool guided by the scope and the procedure is over within 20 minutes.
ACTUALITY
Now I've pretty well finished now this release. We'll do a little manipulation at the end. But you can see that we've come behind the [indistinct word] biceps and cleared all the scar from behind here. So she's now got pretty good rotation, she's got pretty good elevation there and I'm reasonably happy.
BUNKER
When we did our careful study of these patients about five years ago it showed that one third of the people were greatly improved the day after their surgery and what I mean by that is that their pain had gone, that they were able to sleep at night and that they were moving their arm in a near normal fashion. About 80% are at that stage by two to three weeks, there's a small group - about 10% of patients - who fail to settle. What I tell patients that I'm merely releasing it but they have a shoulder that wants to stiffen up so they have to keep it moving and that means some exercises - some gentle exercises, more like Tai Chi, big slow movements - to make sure it doesn't stick down again and that really is critical to the success of the treatment.
PORTER
Mr Tim Bunker.
Angus Wallace, what sort of patients end up needing that type of surgery?
WALLACE
In my practice it's patients who've had a failed intraarticular injection or patients who are diabetic. Diabetic patients do get frozen shoulder slightly more commonly than the average patient and when they get it they can get a fairly vicious form of frozen shoulder which is quite resistant to treatment and even with Tim's release I've seen a number of patients who have diabetes and a frozen shoulder when the release has not always succeeded.
PORTER
Now when we were listening to that report there with Tim you were saying that a lot of people experience frozen shoulder for the first time in a car, can you explain?
WALLACE
Yeah, very common story is that somebody's in the car, usually the lady, she stretches into the back to get her handbag out of the back seat and suddenly feels a severe pain. And she thinks that she has injured her shoulder, in reality what has happened is the shoulder has started to stiffen up and this is the first time that she notices that it's actually stiff because suddenly she can't reach where she's been able to reach before.
PORTER
A familiar scenario in the consulting room. Let's move on to arthritis - is it a common problem in the shoulder?
WALLACE
It is not as common as the hip. The thing that's changing is that people are getting older, we're living longer, and we're seeing more people now with arthritis because it is age related and we're also seeing more referrals because patients aren't as tolerant as they were 50 years ago, 50 years ago they would put up with anything, now they're actually coming forward and saying I've got a painful shoulder can you do something for me.
PORTER
The pain would be the main driving symptom, what about limited range of movement - what happens to an arthritic shoulder, does it seize up?
WALLACE
It does seize up gradually and you find that you get the same pattern of stiffness that you see in a frozen shoulder. But it's quite clear that this is a solid block to movement, much more solid than you see in a frozen shoulder.
PORTER
Angus, what about movement versus rest in an arthritic shoulder, if the joint's becoming damaged should you be resting the shoulder joint, it doesn't take to rest very well does it?
WALLACE
No it doesn't and it's always a very fine balance between keeping the shoulder mobile enough so that you're getting the best out of it and overdoing it when you have arthritic symptoms. So what we want people to do is to carry out what we call pendulum exercises, keep it moving but not overstrain it until you've actually got a reasonable movement back.
PORTER
So resting the shoulder can actually cause more problems than it solves?
WALLACE
Yes it can and the muscles that control shoulder movement, if they rest too much, then they waste, they shrink, and they're not working so well and the shoulder gets more painful when that happens. So you do want to keep the joint moving, you want to keep the muscles moving, we actually don't like slings because they help the muscles to waste.
PORTER
Well the ultimate treatment for an arthritic joint is to replace it - in much the same way as with knees and hips. But, despite the fact that shoulder replacement was first attempted over a hundred years ago, it's still a relatively uncommon procedure.
Steve Copeland is President of the International Shoulder and Elbow Society and the man behind the Copeland hemi-athroplasty, which involves resurfacing the ball part of the damaged joint.
COPELAND
We don't have to do that major invasive surgery, i.e. like the original hip replacements, they had a stem and cement going down the middle of the leg bone and cemented in place, exactly the same was for the shoulder. And now for arthritis we're really - it's just the surface of the joint that's destroyed and become abnormal and that's really where I came in, I really wanted to make it less invasive and just replace the surface of the joint and make that smooth again.
PORTER
We have one of your joints in front of us here, well basically describe what we're looking at.
COPELAND
Yeah. During the operation you've opened the shoulder joint and you have to dislocate the joint to see the ends of the bone, so you take the end of the bone which by this time with arthritis it's lost the nice smooth articular cartilage - the glossy stuff on the end of the bone has worn through so there's a roughened edge to the bone. So then we with a little jig find the centre of the top of the arm bone and then reshape it to fit the undersurface of the new joint - the new metal joint - so that a central hole is drilled and then a thing like a mushroom is implanted, as you can see, with the central drill hole that's put on top of the arm bone to put a new surface on the joint.
PORTER
So the stem of the mushroom goes into the hole that you've drill in the ball at the top and the cap of the mushroom sits over the top.
COPELAND
Indeed. And fortunately we do not have to cement this in place now because we've got better methods of fixing joints and if you can fix it without cement then all the better. So that this particular design is coated on the inside with a white chalky like substance so that your own bone grows into it. So when we put the metal cap on it's just impacted in place and then a later biological fix occurs whereby the bone actually grows into the coating of the joint.
PORTER
So what would you be doing for this patient - you've done that to that side, is that all you need to do?
COPELAND
Well funnily enough it is and we've come to that conclusion by a very circuitous route because it's obvious one does a total shoulder replacement you replace both sides of the joint if you want good pain relief. And that's the way we started out, this is back in the early 1980s, when I was first doing this surface replacement. And then there are certain times when you actually can't do a socket, it's too badly worn or it's too badly misshapen or something and you then just do - I've described as a hemiarthroplasty, just doing the ball and leaving the socket. And it became obvious over many years that actually those were really doing very well and doing surprisingly well. So then we started deliberately doing it and they too have done really rather well.
PORTER
When was the first one of these?
COPELAND
Ninety eighty six - ninety eighty six.
PORTER
So we're quite - we're 20 plus years down the line.
COPELAND
Yeah, 20 years, 21 years on yeah.
PORTER
So what sort of results, I mean if a patient comes to you and you're offering them a replacement and they ask you how's successful it's going to be, probably their first ...?
COPELAND
Yeah that's probably the first thing they'd ask and I'd give the same answer - whether I did for total knee or total hip replacement - that one expects it to last for the rest of their life, if it lasts anything other than that I would be deeply disappointed.
PORTER
And who's getting these joints, the sort of person that you think should be considered for replacement surgery of this type?
COPELAND
Well again people always think in terms of what does the x-ray show, what does the MRI - so it really doesn't depend on that at all. It's pain, pain, pain, pain is the indication for doing it. The two common indications: long term osteoarthritis and rheumatoid arthritis, then you'll get degeneration of the joint, wearing through of the [indistinct word] and they would get more and more painful, they get more restriction of motion and you get to the level where you just can't hack it anymore and something's got to be done.
PORTER
Much the same as with a knee and a hip?
COPELAND
Exactly the same as the knee and the hip. When do you do a hip replacement? When you find you can't manage anymore. Now for different people, that's going to be, if you're a little old lady living in a flat, when she can't go from her toilet to her kitchen whatever, she's in trouble. Whereas for a working man if he can't walk a mile during his day he's in trouble, so that varies totally with the patient.
PORTER
The patient's of course interpretation of success is how much they can use their shoulder and whether they're pain free, so in those terms how successful is the operation?
COPELAND
Well the results of shoulder replacement, as for knee and hip, depend totally on the diagnosis why they went in in the first place, so that the rheumatoid arthritis, where it's not actually just the bone that's involved, it's the soft tissues, the muscles and they get stiff, you can put a nice new shiny joint in but sadly they've got a lot of other problems that you can't replace and you can't predict normal shoulder function in there. But really answering your question: the big group is the osteoarthritics, what can they do, I would expect them to play golf, to get back to their sporting activities, I would expect them to do activities of daily living, they can pretty much do anything they want to do. And they would be something in the order of sort of 80% of shoulder function, getting back to that.
PORTER
Jill Douce had her shoulder resurfaced by Mr Copeland last October.
DOUCE
Many things are much easier now, I'm able to lift things better, I still have a problem in reaching up for things and I often have to use my left hand to just push my right arm up a little bit because it goes so far and then it doesn't want to go any further. And I haven't a lot of power to push with it yet but it is improving and I'm looking forward to this time next year when I hope it'll be as good as new.
PORTER
Jill Douce and her surgeon Steve Copeland talking to me at the Reading Shoulder Unit.
Angus, we haven't mentioned the role of the neck in shoulder symptoms - we've made a lot about getting the diagnosis right and that's a common mistake isn't it.
WALLACE
Yes it is. And what we have to remember is that pain in the shoulder and upper arm can be produced not only from the shoulder but actually from the neck because the nerves that come out between the vertebrae in the neck, the little blocks in the neck, these nerves can get trapped and if they are trapped because of arthritis, as you get a bit older, they give you the same pain as you get when you have a shoulder that's painful and we have to differentiate between the two.
PORTER
And of course we see a similar problem in people with lower back trouble, they can get pain in the hip and knee from sciatica and related problems. Very briefly, how would we differentiate, what would suggest to you from the story perhaps or from examining the patient that it's a neck rather than shoulder?
WALLACE
I think the trick is to go in there and check they've got a good range of neck movement and that the neck movement doesn't produce any pain. As a doctor, when I exam the neck, if during examination of the neck the patient gets pain going down to the shoulder and it's the same pain they're complaining of the diagnosis is very clear and yet the patient doesn't actually realise that a lot of the time.
PORTER
We must leave it there. Professor Angus Wallace thank you very much.
Don't forget you can listen to any part of the programme again by visiting our website at bbc.co.uk/radio4 - where you will also find useful links and contacts. And if you don't have access to the internet then do call the Radio 4 Action Line on 0800 044 044.
Next week's programme is all about the ageing eye - including why after nearly 45 years of no specs, I can't now read a newspaper without them.
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