Ask the Elbow&Shoulder Specialist
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 next step.
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 the future.
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 preserved.
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 from happening?
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 and reviewed.
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 resurfacing implants?
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 traditional implants.
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 'transcripts.’
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 etc.
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 this first
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 exercises.
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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