Online Health Chat with Dr. Eric T. Ricchetti
September 20, 2010
Cleveland_Clinic_Host: Unlike sturdier ball-and-socket joints, the shoulder is like a golf ball on a tee, he says, carefully stabilized by a complex arrangement of capsule, ligaments, tendons and muscles that are prone to injury and degeneration. Shoulder instability, stiffness, arthritis and rotator cuff injuries will be discussed.
Eric Ricchetti, MD, is a physician in the Upper Extremity Center in the Department of Orthopaedic Surgery. 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.
Dr. Ricchetti's interests in shoulder and elbow pathology include joint replacement and arthroscopy, rotator cuff tears and other tendon and ligament problems, sports injuries, and trauma. Dr. Ricchetti is very active in shoulder and elbow research and has authored a number of publications and book chapters, including presenting at regional and national conferences.
To make an appointment with Dr. Eric 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 levelandclinic.org/ortho.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Eric T. Ricchetti. We are thrilled to have him here today for this chat. Let’s begin with the questions.
ewiley: I suffered a broken clavicle on Nov. 1, 2009. I was off work until February 6, 2010. I took physical therapy for my injury. I am still experiencing constant pain. My question is how long will I continue to have this pain, or will it every go away?
Dr__Eric_Ricchetti: It may often take up to a year to fully recover from a fracture, but the reason for pain can be due to a number of factors: a nonunion or malunion of the bone; incomplete rehabilitation. This should be determined by your physician to best address your pain.
Cathy_S_: I was recently cleaning house & had to push a heavy object up with my left arm. While pushing, I heard a pop, pop, pop near my shoulder joint. Since then, I've worried that I damaged something. I can lift my arm, but it's a little sore, and I hear more noises than before when rotating it. I'd like to go back to swimming, my favorite exercise. Can pushing up on heavy loads cause damage? If so, what is the remedy? Also, would resuming swimming be O.K.?
Dr__Eric_Ricchetti: Hearing a pop in your shoulder can be a sign of damage, such as a tear in the rotator cuff. Rigorous activities, such as swimming or heavy lifting, could potentially cause further damage, but the only way to know if you truly have a problem is to have your shoulder evaluated by a shoulder specialist. I would recommend doing this if your symptoms do not resolve.
argentina: I have osteoarthritis of the shoulder. I have been taking over-the-counter anti-inflammatory drugs for a few months, but the pain is getting more difficult to manage every day. Are there other options to manage my pain? I have heard about surgery but I am afraid just thinking about it. Thanks in advance for your advice.
Dr__Eric_Ricchetti: One other non-operative treatment to consider prior to surgery would be injections. Cortisone injections can provide relief for months to a year.
Viscosupplementation (artificial joint fluid) is an injection option for the shoulder that could potentially last even longer. These injections should be done by a shoulder specialist or under image guidance.
cullint: I dislocated my shoulder many times in high school / college, again was 17 => 22 years old, had two surgeries...putty plat, bristo (sp?), I'm now 48 years old and am having significant pain, especially when sleeping. I'm guessing scar tissue or arthritis? What would my best course of action be to take? Thanks.
Dr__Eric_Ricchetti: Your pain now is most likely due to arthritis. This can be managed initially non-operatively with NSAIDS (non steroidal anti-inflammatory drugs), light physical therapy and an occasional cortisone injection.
If this fails to treat your pain and your arthritis is advanced enough, a shoulder replacement may be an option for you.
talon: When is it best to get a cortisone shot after a shoulder has been injured and there is severe pain?
Dr__Eric_Ricchetti: A cortisone shot may be helpful for pain, but it depends on the injury. If there is a true tear in the shoulder from the injury and surgery is required, cortisone injections may not be appropriate. A shoulder specialist such as myself, or one of my colleagues would be happy to evaluate you. You can call 866.275.7496 for an appointment at Cleveland Clinic.
WILLCAM: Any limit to the number of cortisone shots a person might have before considering a different treatment option (like surgery or shoulder replacement)?
Dr__Eric_Ricchetti: If the injections become too frequent (< every 3 months in frequency) we worry that it may impair the healing process after surgery.
WILLCAM: Follow up question on the cortisone injection. Why would cortisone NOT be appropriate when surgery is required? What does cortisone do that would interfere with surgery?
Dr__Eric_Ricchetti: There is some evidence that cortisone can temporarily impair tendon healing. Therefore it is not recommended if you plan to have surgery soon.
Lisa47: I have Stage 4 arthritis in my shoulder. I have pain that can be severe and very limited mobility. I had arthroscopic surgery and injections. But now they do not help. Would another round of PT potentially be helpful? What else do you suggest?
Dr__Eric_Ricchetti: Physical therapy often may aggravate more advanced arthritis, but sometimes light stretching or strengthening exercises may help. Warm water exercises may also be beneficial. If all these options fail, joint replacement would be the surgical recommendation.
Lisa47: I have had arthroscopic surgery for my shoulder. I have had 3 injections into the joint that helped. The last injection did not help and the radiologist had trouble "getting into" the joint. What other options do I have now other than shoulder replacement?
Dr__Eric_Ricchetti: If your arthroscopic procedure was done for arthritis, typically the only other recommended surgical intervention is a shoulder replacement. This would depend on your degree of arthritis and your age.
Other non-operative interventions include other types of injections, such as cortisone or viscosupplementation, depending on what you have already received.
Lisa47: Would a cortisone injection in one place impact a tendon healing in a different body part?
Dr__Eric_Ricchetti: No - this is usually a local effect. Steroids taken orally or intravenously can have effects throughout the body.
hurtin2: I had shingles 4 yrs ago and still experience pain in shoulder and neck. I have bi-weekly massages, but the pain is still present. What can I do to alleviate this pain?
Dr__Eric_Ricchetti: Shingles is typically a neurological process. I would recommend an evaluation with a neurologist or pain specialist.
Rotator Cuff Tears
WILLCAM: I have a tear of the rotator cuff that happened when I had a very bad fall on the elbow. Surgery has been recommended to reattach the tear. A friend who had surgery tells me I should consider cortisone injections first. When is cortisone best used?
Dr__Eric_Ricchetti: Cortisone injections are typically recommended in patients with smaller tears who are older and less active. If your tear is large and you are younger (<60 yrs.) or more active, surgical repair is typically recommended as the initial treatment.
talon: When should a complete cuff tear be repaired for the best outcome, if it has torn from the insertion site due to an accident?
Dr__Eric_Ricchetti: Rotator cuff tears most commonly tear from the point of insertion to bone. Typically the best outcome for a repair is when it is done sooner rather than later.
talon_1: If a tear is suspected, should one get an x-ray or an MRI?
Dr__Eric_Ricchetti: Rotator cuff tears are soft tissue injuries that are not routinely picked up by X-ray. MRI is the preferred study to detect these.
JackS: Can arthritis set in after having Rotator Cuff tear?
Dr__Eric_Ricchetti: Yes. Typically osteoarthritis occurs on its own and is not frequently associated with rotator cuff tears. But - very large rotator cuff tears may lead to arthritis a condition we have termed "cuff tear arthropathy."
trainor: I need left rotator cuff surgery. I have a slight tear in it plus I have a little Arthritis in my left shoulder. How long is rehab? Do I need an overnight stay? How long is physical therapy - 6-8 months?
Dr__Eric_Ricchetti: If the procedure is performed arthroscopically you typically go home the same day of surgery. Recovery following rotator cuff repair can take 6 months or longer to get maximum improvement. Formal physical therapy can last anywhere from 6 weeks to 6 months.
SAHodes: How do I know if shoulder resurfacing is right for me?
Dr__Eric_Ricchetti: Resurfacing is typically recommended in patients with advanced arthritis that has failed non-operative treatment and who are too young for a more traditional shoulder replacement surgery.
rwilson: I am 43 with moderate pain in both shoulders. I have had one surgery on the right shoulder for a labraum repair. While in surgery he noticed pretty severe arthritis. My rotator cuff strength is good. Pain is becoming a problem. If I lie on my back and put my hands to the sky and then let them drop behind I get severe pain. My left shoulder is now becoming worse than the right. Would I be a candidate for the Ream and Run surgery?
Dr__Eric_Ricchetti: Ream and Run surgery is a technique of shoulder replacement that can potentially be used in younger patients, such as yourself, who may be candidates for a joint replacement because of advanced arthritis. It is a form of hemiarthroplasty in which only the ball of the ball and socket is replaced. If you are interested in looking into this possibility further, you should have your shoulder evaluated by a shoulder specialist.
rgallagher: How long will I be out of commission after a complete shoulder replacement?
Dr__Eric_Ricchetti: We typically give a 6 month time-line for complete recovery with no restrictions; however you may feel comfortable using your arm at waist level within a few weeks of surgery. You are also allowed to start using your shoulder for light activities after 6 weeks. Most people have significant pain relief within a few weeks of surgery.
JWSMITH65: I had arthroscopic surgery 5 weeks ago, no tear. Surgeon cleaned up degenerative arthritis. I have had PT for a total of 3 weeks. I have full range of motion with some pain, mostly in muscle areas. Is this normal?
Dr__Eric_Ricchetti: Yes - completely normal. It is very common to experience some aches and pains early on after surgery. These symptoms should improve over time. Be patient with your physical therapy.
Lisa47: Does shoulder replacement surgery help both pain and mobility or only one of these?
Dr__Eric_Ricchetti: Shoulder replacement surgery will help both pain and mobility. Typically the surgery is performed first and foremost as a pain relieving operation, but mobility is also improved.
SAHodes: Can you qualify too young?
Dr__Eric_Ricchetti: We worry more in younger patients that their shoulder replacement will wear out over time because of their age and activity level. But there is no hard age cut-off, it is determined on an individual basis.
whallon: Now they have "female" knee replacements (smaller). Is the same true for shoulder replacement?
Dr__Eric_Ricchetti: No - but shoulder replacement prosthesis come in a wide variety of sizes to fit both genders.
shoulder1: I have frozen shoulder and NEVER had injury to shoulder. It got so bad it was "slipping" out of the socket. 5 professionals thought I was crazy. A PT acknowledged me, saying tendon slipping from a sheath (?). This has been since 5/09. I have had cortisone injections and MRI. Nothing. Someone suggested shoulder manipulation. Would you think that would be beneficial?
Dr__Eric_Ricchetti: Based on your description, it is difficult to determine if you have a frozen shoulder or some other problem. Typically, the treatment for frozen shoulder is physical therapy focused on stretching exercises. This can often take a year or longer to completely resolve.
shoulder1: I am a healthy 53 yr old female that's never had a shoulder injury. I developed frozen should in May 2009. I went to my General Practitioner, and 3 ortho surgeons plus another specialist. Had MRI that showed nothing, had 2 cortisone shots that did not help. They recommended a manipulation. How successful are these procedures?
Dr__Eric_Ricchetti: Typically the initial recommendation for treatment of frozen shoulder is physical therapy. If you have not had this, I would recommend this as a 1st option prior to shoulder manipulation. A manipulation may be an option after failure of a prolonged course of physical therapy.
kmgdetroit: About a month after open heart surgery, I developed a "frozen" left shoulder. I have done exercises over the past 3 months and have seen very little results. Is a frozen shoulder common after surgery? How long could this frozen shoulder possibly last and what is the next step?
Dr__Eric_Ricchetti: Yes - frozen shoulder can typically occur after an event like surgery. It may take a year or longer for frozen shoulders to completely resolve. Try to be patient with your physical therapy because it can be a lengthy process.
kmgdetroit: Why does surgery like open heart surgery cause a frozen shoulder? Is it the physical aspect or is it from scar tissue growth?
Dr__Eric_Ricchetti: We do not really know for sure, but we do see this happen on occasion. It may be the trauma and inflammation from the surgery that causes it to occur.
mkmv61: My mother, who is 72, broke her shoulder over the weekend. How long will her recovery take, and will she need any kind of therapy? Also, will this increase her chance of developing osteoporosis?
Dr__Eric_Ricchetti: Whether she has surgery or is treated non-operatively, complete recovery can take between 3-6 months. Physical therapy is typically recommended as a part of both treatments, once enough healing has occurred.
Fractures do not increase your risk of developing osteoporosis but are rather a potential sign of insufficient bone density. An osteoporosis evaluation is typically recommended after such fractures.
SAHodes: Occasionally when I work out and perform either a dumbbell chest press or shoulder press (again with dumbbells only), my right shoulder feels like it "pops out" and I have to drop the quickly drop the weight. The shoulder is completely fine afterward - no dislocation or pain. What is that about?
Dr__Eric_Ricchetti: This could be true. Sometimes the shoulder can partially dislocate (sublux) with these maneuvers.
A shoulder specialist such as myself, or one of my colleagues would be happy to evaluate you. You can call 866.275.7496 for an appointment at Cleveland Clinic.
Complicated_shoulder: I had a thermocapsular shift on my R arm in '99 (I was 18) I recovered & played softball until July'09 when I tore my infraspinatus. I had surgery to repair but had post-op pain & motion loss. Sept'09 I had surgery & was found to have an extremely red "angry shoulder". My Dr. thought I was allergic to the stitches & took them out. In Oct &Nov, I had shoulder manipulations for frozen shoulder. I kept having redness, swelling, warmth & ripping pain & my Dr refused to do another surgery, so I found a new surgeon. He did surgery Feb '10 & found TONS of scar tissue & a shoulder capsule tear, which he repaired. I continued to have pain & my deltoid stayed swollen & tight. I had 2 cortisone shots & 2 rounds of prednisone without relief. I had my 6th surgery, July '10 & found TONS of scar tissue again & a supraspinatus tear now. 6 weeks post-op I can only lift my arm up 30 degrees active (full passive). I have severe deltoid atrophy despite rehab and CPM machine. Do you have a patient like me? Are there any clinical trials for scar tissue build up? Would anyone be interested in doing a case study on me to figure out what is wrong so no one else will have to go through this?
Dr__Eric_Ricchetti: I agree that you do have a complicated shoulder at this point, having had so many surgeries. Unfortunately, there are no clinical trials that I am aware of looking at treatment of scar tissue in the shoulder. Scar buildup is always a concern whenever the shoulder or any other joint is operated on multiple times. There is likely not an easy answer in how to best treat your shoulder moving forward, but it is important to rule out more worrisome causes for your stiffness and loss of function, such as an underlying infection.
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 shoulder pain and treatment options.
Dr__Eric_Ricchetti: Thank you for having me. I have enjoyed the time answering your questions.
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