Online Health Chat with Dr. Eric Ricchetti
September 12, 2011
Cleveland_Clinic_Host: Elbows and shoulders are
essential tools that allow you to work, play, and perform everyday activities.
In fact, how well the hands, wrists, arms, and shoulders interact depends upon
the integrity and function of the related ligaments, tendons, muscles, joints,
and bones. Problems in any of these can affect upper extremity function – from
the fingertips to the shoulder blades – causing major disruptions at home and at
work, and negatively impacting quality of life.
With more people trying to stay fit, shoulder problems
are on the rise. Currently, shoulder pain or problems account for nearly 20
percent of visits to the orthopaedic specialist’s office. Most shoulder problems
can be solved without surgery. But if shoulder pain is severe or movement is
restricted, it’s time to seek help from an orthopaedic expert familiar with the
full spectrum of shoulder problems and treatments.
Eric Ricchetti, MD, is an orthopaedic surgeon
specializing in the shoulder and elbow. His interests include joint replacement
and arthroscopy, rotator cuff tears and other tendon and ligament problems,
sports injuries, and trauma. After receiving his undergraduate degree from Yale
University and his medical degree from the University of Pennsylvania School of
Medicine, Dr. Ricchetti completed his internship and residency in orthopaedic
surgery at the Hospital of the University of Pennsylvania. During his residency
training, Dr. Ricchetti also completed a year of dedicated research in the McKay
Orthopaedic Research Laboratory at the University of Pennsylvania. Following
residency, he completed a fellowship in shoulder and elbow surgery at Thomas
Jefferson University Hospital, the Rothman Institute.
To make an appointment with Dr. Ricchetti or any of
the specialists in the Department of Orthopaedic Surgery at Cleveland Clinic,
please call 866.275.7496. You can also visit us online at clevelandclinic.org/ortho.
Cleveland_Clinic_Host: Welcome to our Online Health
Chat with Dr. Eric Ricchetti. We are thrilled to have him here today for this
chat. Let’s begin with some of your questions.
Medications and Next Steps
daveh: I have soreness on one shoulder when I sleep on
that side, or with certain movements -- never sharp pain. It hasn't improved
after three weeks. It probably happened after brief jogging with a heavy
shoulder-strap bag. What are the next steps for me?
Dr__Eric_Ricchetti: You can try an over-the-counter
anti-inflammatory (Advil®, Aleve®) for a few more weeks
with avoiding strenuous activities for the shoulder. If it does not go away,
then it’s a good time to see a specialist. The next step would likely be a
course of PT (physical therapy).
Jojota: When I move my right shoulder in a certain
way, I hear a pop, which is very uncomfortable. Not much pain, but I've become
afraid to exercise my arms because I don't know if it would cause any further
damage. Please advise what I should do to remedy this condition. Thank you very
much for your response.
Dr__Eric_Ricchetti: Anti-inflammatories (Advil®,
Aleve®) can help, and avoiding activities that are strenuous to the
shoulder. If that does not improve it, consider evaluation by a shoulder
specialist. You may need a course of PT as the next step.
Heath: Similar question to daveh, but I am on Coumadin
and can't take the NSAID products. Do you have any other recommendations beside
Tylenol®? Thank you.
Dr__Eric_Ricchetti: Nothing else over the counter.
Other options would be cortisone injections or a prescription pain medication.
bbc: In terms of taking an anti-inflammatory, I have
bad gastric reflux. What do you recommend I take that won't hurt my reflux?
Dr__Eric_Ricchetti: Some of the prescription
medications are often less harsh on the stomach, but not always. Celebrex®
is the most common one that is supposed to cause fewer problems with reflux.
gatorfrog: I have been diagnosed with tendonitis in my
shoulder and biceps. I have had shots of cortisone and pain medication, but that
doesn't seem to help. I have tried doing exercises for my shoulder area and that
helps some. I would like to know what I should consider short of surgery. Thank you!
Dr__Eric_Ricchetti: If the exercises are helpful. You
may benefit from a more directed and extended course of outpatient PT. I would
consider this as the next step if you are trying to avoid surgery.
jfkacres: After five months of physical therapy for
tendonitis in my right elbow, I took myself out and went to "complete rest as
possible." My elbow improved within a few short weeks. How is one to know when
PT might exacerbate a condition, not repair it?
Dr__Eric_Ricchetti: There is some trial and error
involved with tendonitis and PT. Sometimes, rest is more beneficial initially
than PT, as PT can exacerbate symptoms if it is too aggressive early on. If your
symptoms do go away with rest, it may then be useful to get back into PT to help
condition the arm and prevent recurrence in the future.
swrobel: Is there an alternative to surgery for slight
impingement of the rotator cuff? I have heard too many bad outcomes from should
surgery, although I had successful one on my left shoulder. Now I am being
advised that I would benefit from having the right one done (after falling too
many times skiing.
Dr__Eric_Ricchetti: The mainstay of treatment for
impingement is PT, sometimes with a cortisone injection, if needed. I would
recommend these options as a first step if you are trying to avoid surgery.
jpm: I injured my shoulder about a year ago, a grade 3
separation. It has mostly healed, but occasionally, I have problems where my
shoulder feels like it dislocates. It takes about three to four weeks for it to
go back to normal. Are there strengthening exercises or anything else that can
be done to help my shoulder so that it goes completely back to normal?
Dr__Eric_Ricchetti: The first thing to try would most
likely be shoulder exercises to strengthen the shoulder. These can be prescribed
as outpatient PT, and a home program can be started. If these are not solving
the problem, you may need your shoulder further evaluated, such as with an MRI
swrobel: Continuing on with my previous question - I
did three months of PT and reached a plateau. PT therapist said she could not do
more, so that's when the doctor said surgery. Is there evidence after stopping
PT for three months and working on more focused PT that it might work to
alleviate the impingement? Recommendations?
Dr__Eric_Ricchetti: If you haven't had a cortisone
injection yet, that would be worth trying now. This may improve your shoulder
and allow the PT to be much more beneficial.
trueheart: I have dislocated my shoulder twice in two
separate incidents (about 18 months apart). I now have troubles with my
shoulder. It gets very stiff, is uncomfortable when I try to sleep, does not
have the same strength, and some of my activities are restricted (mostly
sports-related, exercise, lifting things). Will I always have trouble with this
shoulder and should I accept that, or is there anything that can be done?
Dr__Eric_Ricchetti: I would recommend having it
evaluated. Your shoulder may respond well to something as simple as physical
therapy, which can allow you to get back to activities you want to do. If PT is
not helpful, surgery may also be an option to fix the shoulder.
jinord: I have tendonitis inside my right elbow. Ice,
heat, rest do not seem to help. The condition has lasted six months. What else
can I do?
Dr__Eric_Ricchetti: The next step would be to see an
elbow specialist and start a course of therapy, and also potentially try a
cortisone injection. There can be certain braces that can be prescribed that may
help as well.
jfkacres: Years ago, after receiving a cortisone
injection in my left shoulder, the doctor suggested sleeping on my other side
and placing a pillow under the injured elbow/shoulder/arm area to keep it from
"pulling" away from my body. I have been sleeping this way ever since and have
not required additional treatment on that shoulder!
Dr__Eric_Ricchetti: Glad it worked!
swrobel: Do you recommend a general practitioner do a
cortisone injection or is it a relatively precise injection based on an MRI. (I
had one done, which is why the doctor said surgery would probably be helpful.)
Dr__Eric_Ricchetti: Orthopaedic surgeons do shoulder
injections much more frequently than general practitioners. Certain injections
are only done by shoulder specialists.
kiea9: I injured my arm about three years ago when I
threw a small stuffed toy across the room. X-rays came back clear. MRI showed "a
little something." I had physical therapy and exercises since. I recovered range
of motion, but am still bothered by pain, especially when I do much repetitive
motion. I continue my PT exercises at home twice a week. I'm wondering if there
is anything further I can do to get healed up "all the way."
Dr__Eric_Ricchetti: If the MRI looked OK, you may want
to try a cortisone injection in combination with continuing your exercises, to
see if that takes care of it.
kiea9: About 6 months after my throwing injury when I
was almost done with PT, I had three cortisone injections. They helped somewhat
for a limited period of time. Since then I have continued my PT exercises at
home gradually decreasing until once a week as I gradually improved. This took
us to about three years after the injury or six months ago. Then things seemed
to be getting a little worse. So, for the last several months I bumped it up to
twice a week, but haven't really improved. Any other ideas?
Dr__Eric_Ricchetti: If it’s been going on that long,
it may be good to get a new MRI to make sure nothing worse is going on.
LJE: I had left shoulder surgery in May of 2010 for an
impingement issue. I have some pain now that has returned. So, do I have to go
through having another MRI? I am no longer able to tolerate MRIs as the noise is
exacerbating my tinnitus. Are there any other X-rays or tests that can be used
instead of MRIs? Thank you.
Dr__Eric_Ricchetti: MRI is the best study to evaluate
the rotator cuff. If the symptoms are only mild, you may do OK with a course of
PT to address the problem, but if that doesn't help, a new MRI would be the best
swrobel: Can Cleveland Clinic provide a list of
surgeons who only do shoulder surgery?
Dr__Eric_Ricchetti: You can search our Cleveland
Clinic Web site (www.clevelandclinic.org) and type in "shoulder" in the "Find a
Doc" section to see all of our surgeons who do shoulder surgery. Doctors are
identified as surgeons and non-surgeons on the website.
denalijones: If warranted, would you do a shoulder
replacement on a 30-year-old?
Dr__Eric_Ricchetti: In certain situations, yes, if
arthritis is advanced enough and debilitating enough for the patient. Typically
we do not replace the socket of the shoulder -- only the ball (hemiarthroplasty)
-- in a very young patient because the socket can wear out over time.
Animaldoc: I had rotator cuff surgery in 2008 and
again in late 2010 and did lots of PT after each surgery. I still have quite a
bit of pain at times and a loss of function. My surgeon says there is nothing
else he can do because he thinks I’m too young for a recommendation of shoulder
replacement. I'm 55 years old, and he says my tendons and soft tissues are in
bad condition. Is there anything else on the horizon? (I also had shredded
biceps tendon tacked at the same time.)
Dr__Eric_Ricchetti: Sometimes, another attempt at
rotator cuff surgery is still possible, depending on the quality of the tissues.
We do have certain graft tissues we may use in these situations to try and
reinforce the repair. More research is being done on ways to get these tissues
to heal better, and more things -- such as the grafts -- will likely come out in
Dr__Eric_Ricchetti: Resurfacing is usually aimed at
younger patients (40s and younger) to try and conserve bone, with the idea that
the implant may wear out in the patient's lifespan (due to their young age). A
revision implant could then be easier to put in down the line with more bone
carolj23: Regarding HHR again, if one goes into the
replacement surgery with stiffness, in your opinion, would it take much longer
to be pain-free afterward? In other words, would a long period of pain be not unusual?
Dr__Eric_Ricchetti: Stiffness typically improves after
a resurfacing or a hemiarthroplasty because it is usually part of the arthritic
process that is being treated. People typically notice a significant improvement
in pain and range-of-motion within the first six weeks after surgery, even
though they continue to improve after this.
papa_bear: What are the limitations to someone who has
had surgical repair of torn muscles in the shoulder from a sporting accident?
Will that person ever get back to 100 percent normal? Will they be able to go
back to playing sports? My son is 23 years old.
Dr__Eric_Ricchetti: There are limitations during the
recover process from surgery. This usually involves lifting restrictions and
avoiding certain activities for five to six months. The goal afterward, though,
is to get back to unrestricted activity.
l_grant: Eight months after shoulder surgery, my range
of motion is still only at about 75 percent. I did the full extent of PT and
continue to do the exercises/stretches at home daily. Is this normal? I had slap
repair. The doctor is considering manipulation. Can you please explain what this
would entail? Can I get back to full range of motion without the manipulation if
I continue with the exercises/stretches? If so, how long would it take?
Dr__Eric_Ricchetti: Range of motion can improve
typically for up to a year after surgery. Manipulation is typically considered
before this time if the stiffness is very severe. If you are at 75 percent, you
may want to give it a little more time, with continued stretching for the
shoulder, to see if you improve further.
cause_n_effect: My son has complained of his elbow
hurting him lately. I don’t know if there was an initial injury, but he says
that he hits his elbow/"funny bone" regularly and it is very painful. It is only
his right arm. He never had this sensitivity before. Do you have any idea what
may be causing this and how I can help him?
Dr__Eric_Ricchetti: The "funny bone" usually describes
the ulnar nerve being irritated on the inside of the elbow. It may go away with
something simple like padding the elbow and taking an anti-inflammatory
medication (Advil®, Aleve®) until the symptoms die down.
If it persists, physical therapy can be helpful as the next step.
vpm: I have tingling/pain in my hand. The doctors have
told me that I have carpal tunnel and that I also have issues with my elbow. I
do where a brace on my wrist at night, but I have problems with my elbow mostly
at night that have me waking up a couple of times with numbness and tingling and
occasionally pain, though not severe pain. What can I do at bedtime to keep this
Dr__Eric_Ricchetti: The wrist splint is good to keep
wearing at night. Elbow splints can also be helpful at night and can be fitted
by a therapist.
bbw: I have tennis elbow and have been taking an
anti-inflammatory. Progress is very slow. Anything else I can do to help speed
up the healing process?
Dr__Eric_Ricchetti: Yes, a wrist splint at night can
be helpful; also a tennis elbow strap can be worn for activities that aggravate
it. The next step would be trying therapy for it, and considering a cortisone injection.
happy_days: Does wearing a brace on your elbow help
prevent injuries when playing sports such as tennis or baseball, etc.?
Dr__Eric_Ricchetti: It may. A tennis elbow strap, for
example, can help prevent a case of tennis elbow (tendonitis) from flaring up.
The Clavicle (Collarbone)
eric: I was told by my doctor that I have an AC (acromioclavicular)
joint injury. My collarbone is sticking out. The doctor said that it will heal
fine, but that the bone will always stick out, that the surgery options for this
type of injury are not usually successful and did not recommend it. I don’t like
the thought of my collarbone sticking out forever like this. Is there anything
that you can recommend that might be done to help me?
Dr__Eric_Ricchetti: AC joint separations typically do
leave a bump permanently; but in most instances, they heal without patients
having any problems with the shoulder. If it does become a chronic problem,
surgery can be helpful in certain situations.
denalijones: Is it possible to "reconstruct" the
clavicle? If one is missing a portion and, therefore, doesn't have the needed
shoulder support, is there anything that can be done?
Dr__Eric_Ricchetti: The clavicle is not usually
reconstructed, but there are some situations where the ligaments around the
clavicle are reconstructed to stabilize it and treat the problem.
denalijones: Hi, please help me. I have been to hell
and back with no clear-cut answers. I was in an auto accident about five years
ago. The initial injury was a broken clavicle. Well six surgeries later, I have
almost no cartilage in my shoulder joint. They detached my bicep muscle and
anchored it to my humerus. I have had well over 20 cortisone injections and
Synvisc® injections. I have been told while I do need a shoulder
replacement, it wouldn't necessarily solve my issues because I am missing a part
of my clavicle. There is no support for my shoulder. I am only in my mid 30s and
this has ruined my life. Do you have any suggestions? Would you be willing to
see me or review my records via mail?
Dr__Eric_Ricchetti: It would be best to evaluate your
case and records in more detail because of all the surgeries you have had. You
can contact my office at 216-445-6915 to arrange to have your records sent in
carolj23: In your experience, is there much risk of a
humeral head resurfacing implant to loosen over time?
Dr__Eric_Ricchetti: There is much less data available
on resurfacing implants, compared to the traditional humeral replacements, which
have been around much longer; but to date, the resurfacing implants have not
shown any concern for early or increased loosening.
carolj23: Is there much data on lifespan of
Dr__Eric_Ricchetti: See my answer to the previous
question. This is a newer implant so less long-term data is available, but so
far these implants do not seem to show signs of a shorter lifespan compared to
ztestis: Can you briefly explain mild to moderate
narrowing of the L4-5 and L5-S1 disk spaces?
Dr__Eric_Ricchetti: Hi ztestis - Your question is
referring to a spine issue and I am a shoulder/elbow expert. There are a few
chat transcripts from previous chats by spine specialists that you could read.
Go to www.clevelandclinic.org/webchat and choose the tab that says
reb_robin: One of my son’s shoulder blades seems to be
higher than the other. Is this a skeletal defect or caused by muscle
strength/build because he is left handed and does everything with that arm? If
so, is there anything he can do to correct it? It embarrasses him when people
point it out to him. It does not affect him at all in terms of pain, movement
Dr__Eric_Ricchetti: That may actually be a sign of an
abnormal curvature in the spine, or scoliosis. I would have his doctor check for
mommab: My son is 15 and is the pitcher for his
baseball team. What can I have him do now, as well as during the playing season
that can help prevent injury to the elbow or shoulder?
Dr__Eric_Ricchetti: The most important thing is proper
stretching before and after throwing. The biggest cause of injury is trying to
throw with a stiff arm. His trainer should be able to show him the proper
Cleveland_Clinic_Host: I'm sorry to say that our time
with Dr. Eric Ricchetti is now over. Thank you again Dr. Ricchetti for taking
the time to answer our questions today about elbow and shoulder health.
Dr__Eric_Ricchetti: Thank you for the great questions,
I enjoyed the hour!
jfkacres: This has been very informative--thanks!
Dr__Eric_Ricchetti: You are welcome!
Cleveland_Clinic_Host: To make an appointment with Dr. Ricchetti or any of the other specialists in our Department of Orthopaedic
Surgery at Cleveland Clinic, please call 866.275.7496. You can also visit us
online at clevelandclinic.org/ortho.
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This chat occurred on 9/12/2011
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