Vicky

Good evening, everyone. Welcome to our webinar on shoulder pain treatment and surgery. My name is Vicky, and I’m your host this evening. I’m joined by Consultant Orthopaedic Surgeons, Mr Nik Bakti and Mr Daniel Neen. This presentation will be followed by a question-and-answer session, so if you'd like to ask a question during or after the presentation, please do so using the Q&A icon, which is at the bottom of your screen. This can be done with or without giving your name. Please note that the session is being recorded if you do provide your name. If you'd like to book your consultation, we'll provide contact details at the end of this session. I’ll now hand it over to our experts, and you'll hear from me again shortly.

Mr Daniel Neen

Thank you very much, Vicky.

Good evening, everybody. Welcome to this evening session talking about shoulder pain treatment and surgery. So, I thought what we'd do is start off with some introductions as to what we plan to cover in this session, and then I'd introduce my colleague who's online as well, and then pick out a few conditions just to take you through for some further information as to what to expect.

So, we hope to cover a little bit more about the shoulder in detail, including what makes it tick, how it moves, and the important structures that people sometimes know about or have heard about in the background. We'll talk about some common causes of shoulder pain and injury, some common treatments that we typically use for them, and what to expect during and after that particular type of treatment, and then we'll take some questions and answers, as Vicky said afterwards.

So without further ado my name is Daniel Neen, I graduated medical school from University College London in 1999 which seems a very long time ago now a member of the Royal College of Surgeons of Edinburgh I’ve trained in this region as a registrar and have worked for most the big shoulder bosses in the area I went and did some further subspecialty training in Australia and New Zealand and started as a Consultant in Dartford and Sidcup back in 2015 joining Benenden a year later currently I’m a clinical director of Queen Mary's Hospital and I was lucky enough to have trained in reverse shoulder replacements and was one of the first Surgeons to bring it to Dartford and Gravesham trust and currently things seem to be taking off a little bit with the reverse shoulders and I seem to be doing an awful lot of replacement so the national average currently is about 13 a year and so far this year I’ve done 19 already and I think that echoes what my colleague has found as well Mr Bakti is doing similar sorts of numbers.

Mr Bakti qualified in 2008 from Guys King's and St. Thomas's Medical Schools. He did further surgical training in Oxford but also in the Kent region, where he gained a master's along the way in Orthopaedics from the University of Sussex. Instead of New Zealand and Australia, he did a famous fellowship in Perth, Western Australia, where he learned some of the tips and tricks he uses these days and joined me thereafter as a Consultant in Dartford. He's currently the trauma lead for Dartford and Gravesend and is also a visiting senior lecturer for Canterbury Christ Church University.

So, shoulder pain is actually a very common problem. It's second to back pain nationally. It's related a lot to your age as to what could be causing the pain itself and varies from trauma or dislocation to repetitive movements, such as if you play particular sports or do something particularly strenuous in your job. There are various causes, such as frozen shoulder or calcific tendinitis, that can cause a lot of pain in the shoulder and restrict the range of movement thereafter. Obviously, trauma can cause fractures of the bones, which cause long-term pain and dysfunction, but it can also rip apart some of the soft tissue issues that we also have attached to the bones. Notably, there is the rotator cuff that everybody has heard about but doesn't necessarily know what it entails. Obviously, as we get older, we do wear our joints out, and osteoarthritis comes into play more and more, and we'll talk about these in future slides.

I said it was common; about 14% of the UK population will have a shoulder problem at some point in their life, and every year about 1 or 2% presents to their GP. Most of these will have to do with the subacromial aspect, so 70% is to do with the rotator cuff itself.

Obviously, a lot of this will depend on the anatomy that is causing the pain, and I’ll hand it over to my colleague, Mr Bakti, to talk about the anatomy for you.

Mr Nik Bakti

Good evening, everyone. As I was introduced, my name is Nik Bakti. I’m one of the four shoulder Surgeons at Benenden, and I’m Mr Neen’s colleague at Dartford as well.

So, as you can see on the x-ray, it shows us quite a lot, but there's also quite a lot of overlap. This on the right side of the slide is a normal shoulder x-ray, and we normally use this to diagnose simple things like arthritis and tendinitis, but if it comes to something more complex like the rotator cuff and impingement, then we will require an MRI scan.

Next slide, please. The anatomy of the shoulder joint is quite complex. The reason for this is that, unlike the hip joint, it's very shallow. The picture on top left shows a golf ball on a golf tee, and the reason why it's so shallow and that it's so that the shoulder is supple is that unlike the hip joint, it's very shallow. The picture on top left shows a golf ball on a golf tee, and the reason why it's so shallow and that it's so that the shoulder is supple is that unlike the hip joint, it's very shallow. The picture on top left shows a golf ball on a golf tee, and the reason why it's so shallow and that it's so that the shoulder is supple is that unlike the hip joint, it's very shallow. The picture on top left shows a golf ball on a golf tee, and the reason why it's so shallow and that it's so that the shoulder is supple is that unlike the hip joint, it's very shallow. The picture on top left shows a golf ball on a golf tee, and the reason why it's so shallow and that it's so that the shoulder is supple is that unlike the hip joint, it's very shallow. The picture on top left shows a golf ball on a golf tee, and the reason why it's so shallow and that it's so that the shoulder is supple is that unlike the hip joint, it's very shallow. The picture on top left shows a golf ball on a golf tee, and the reason why it's so shallow and it's so that the shoulder is supple is because it's got lots of freedom movement so that we can do the things that we want to do without the ligaments that's around the shoulder. The muscles that's around the shoulder will very simply come out of its joint because it's so shallow, so we rely on the soft tissues, the tendons, the ligaments, and the muscle to work together to keep the shoulder in joint and make it stable.

Next slide, please. So, this is just a graphical representation of the labium, which is around the socket of the shoulder. Although it looks very thin, it's very important to keep the shoulder joint in place. It acts like an information centre for the shoulder to know that the shoulder is at the limits of its movement, and it tells the muscle around the shoulder to tense up if it's about to come out. The ligament or the tendon that's crossing the joint that attaches to the socket is the bicep tendon. As you can see, it's very close in proximity to the shoulder joint, and any problems with the bicep standing can give you quite a lot of pain around the shoulder. The next slide will show you the capsule in blue and also the other ligaments in the middle, the superior and inferior glenohumeral ligaments, which only means that they attach to the ball and socket together, and all this works in tandem to give extra stability to the shoulder joint. The green section in this picture represents the subacromial space, so this is a space that often gives a lot of pain as well, and as Mr Neen mentioned earlier, it accounts for about 70% of the pain and problems that people present to the GP with, and this is the space that we often inject loc anaesthetic and steroids into.

Please note that this is a picture representing all the rotator cuff muscles around our shoulders. Working from right underneath the skin, you have the deltoid muscle. The top two pictures don't make up part of the rotator cuff muscles, but it's a very important muscle if you do not have your rotator cuff, and we'll discuss this later. The bottom two pictures show the front view and back view of the shoulder with the muscle attachments. These four muscles make up the rotator cuff. Apart from moving the shoulder, they are key in maintaining the stability of the shoulder, and we often refer to them as the dynamic stabilisers of the shoulder. The problem is that the wear out due to age due to repetitive movement or other factors and the supraspinatus muscle which is at the very top of the shoulder is the one that's most at risk to damage.

Next slide, please. This slide really just shows how everything works together, so if you have a torn tendon or a tendon that's working much harder than the others in the rotator cuff, it can cause the whole shoulder to be slightly off balance in terms of its dynamics, and in the long run, apart from pain, it can cause arthritis or even wear of the socket bit or the bit of the shoulder. Next slide, please. So, I’ll hand you back to Mr Neen.

Mr Daniel Neen

So as we mentioned earlier there are various forms of treatment that we can perform for these problems by and large we will always start off with some physiotherapy or some physiotherapy would have happened before you come and see us and the whole point of the physiotherapy side of things is to try and help with that balance that Mr Bakti was talking about injections of steroid are another tool in our arms that we use to try and firstly diagnose on occasion and sometimes treat as well so we can use a mixture of local anaesthetic which will numb the pain and if we inject it into a particular area and your pain dissipates altogether we know that that is the particular area that is causing your issues The steroid in it is a very strong anti-inflammatory, and that helps to calm down the issue, almost like stamping out a fire. Unfortunately, the drug doesn't last forever; it does have a finite lifespan that we normally account for of about six weeks, but again, stamping out that fire can reset the clock and keep the pain away longer. There are various surgical things that we can do, so arthroscopic just means the keyhole surgery bit, so we can decompress or shave away a bit of bone from under the acromion, which is the ledge of bone that you can feel on top of your shoulder, and that increases the space and the amount of movement that the tendons underneath can have. We can take away the arthritis and the joint next door to that area, and we can try and repair the tendons for you. We can try and repair other tendons around the shoulder as well, depending on which ones have been involved. If you have something called a frozen shoulder, we can release it with the keyhole, or we can even do the bigger open surgery, such as replacing the shoulder surfaces all together.

Starting out with the physiotherapy, we should always seek help from professional physiotherapists, such as the ones we have here at Benenden. I believe you can self-refer, or we advise you to go and see the physiotherapist if you've not seen one before. It really takes a lot of time and constant input to try and rebalance the joints and get those muscles working again, so it's not necessarily an instant fix, unfortunately. As it says, exercises and keeping active certainly can help manage shoulder pain because they keep that joint that wants to be so supple in keeping up with the range of movement that it should have, although obviously balancing that against the pain that you may be experiencing can be quite difficult. If, after a few sessions, a physiotherapist tells you that they really cannot do any more for you or that they don't think that it's being successful, they will then refer you on to us for further investigations or potential surgery.

I’m going to talk about a few of those common issues, and I’m going to hand you back to Mr Bakti at this point in time to talk about the most common.

Mr Nik Bakti

That's right, so this is probably the most common presentation that I see in clinic. It's often insidious and onset; it just gradually appears and gets worse, and often this is treated conservatively with exercises and possibly an injection. The problem lies where there is a hook of bone that comes around from the front of the acromion, so that is the bone that's at the very top of your shoulder blade and where your collar bone meets your shoulder blade.

Next slide, please. To explain what happens. As you can see on this x-ray, the red bit is the spur, and if you imagine lifting up your arm to reach something out of your sight, it can then start abutting or impinging onto the top of the ball bit of your shoulder. I think the next slide shows you that this is an MRI scan of what could happen. If this impingement problem is not treated in the long run, it can cause a tear, so the red arrow on this MRI scan represents a tear of the tendon, and what happens with time is that the impingement can cause an attrition to the cuff and possibly a tear.

I think there's a video next. So, this is what happens if you abduct or lift your arm sideways, and if you have a spur on your chromium, it can cause an impingement process at the top of your shoulder. I thought this was quite a good video to demonstrate this because sometimes it can be quite difficult to imagine now.

Next slide, please. Let me know what we can do. As I mentioned earlier, most of the time—I would say more than 50% of the time—this can be treated conservatively with physiotherapy and sometimes sub-injection. Having a sub injection is quite useful because if it does take the problem away, then it tells us that's where the problem is, and even if it comes back after six weeks or so, we know that physiotherapy and injections are not helping, but an operation is likely to help, and this is only something that we would consider once we've failed conservative treatment of physiotherapy and injections. Surgery-wise, there is a keyhole, as demonstrated in this short slide video. What we do is create a couple of keyholes, one from the back, one from the side of your shoulder, and possibly one at the front as well. We introduce a camera from the back of the shoulder, and we use a camera. I don't know if you managed to catch that on the video earlier. We could go back, and can we go back one slide and return to this slide, please? Yes, so we introduce a bur, and what we do with that bur is that we file away that spur that's coming out of the chromium and make a little bit more space for the shoulder to move sideways. Most of the time, if this is done after a failure of conservative treatment, patients do get a good response and a good recovery following the procedure.

On the next slide, please note that recovery is a two-week maximum in a sling. The longer you keep it in a sling, the stiffer the shoulder will become, so we recommend that the sling is really just there to help you recover from the operation itself. Once it's comfortable, we're happy for you to get things moving. Physiotherapy is again key to getting your movement and strength back, and often patients return to work, depending on whether it's a manual job or admin, between 3 and 6 weeks following the operation.

Next slide, please, and I’ll pass you on back to Mr Neen.

Mr Daniel Neen

Right, frozen shoulder, so this is commonly found in middle-aged women, more often in ladies, unfortunately, and it's related to diabetes as well. We know that if you have diabetes, you've got a higher rate of having their scar, so unfortunately, a higher rate of getting it in the other shoulder if you've had it in one. It's also known as adhesive capsulitis, and we don't fully understand it even in this day and age. What we do know is that there are three different stages to it; they last roughly three to nine months each, and the whole process can take a couple of years. So initially, it can be quite difficult to diagnose this because pain is the main issue, and it can come out of the blue for no reason whatsoever. It can be a minor trauma, such as a dog pulling on your lead all of a sudden, or it could be a major trauma, where you've injured your shoulder for some other reason, and then this comes on as a secondary problem. So, pain starts off in this first stage, and slowly you start getting a stiffer and stiffer shoulder in the second stage, or the frozen stage. You end up with a very stiff range of movement. The pain eases off by and large, except for when you try to move it beyond what it is able to do, and then you finally go into the thawing stage or the third stage, where the movements start to come back and everything settles down, but it's a long process.

The picture here just shows that the whole process is involved with the capsule or the skin of the joint, the lining of the joint, and it becomes very inflamed, which is the painful portion, and then it contracts, which is the stiffening up of the actual joint itself.

Normally, we try to treat this as conservatively as we can. We've got to be a little bit careful with physiotherapy, particularly in the first stage, because we know that in the first stage it can actually aggravate the situation, but thereafter it can be a very useful tool to try and help regain some of the range of movement slowly. Pain management is obviously a big thing to do in this whole process. Surgery is one of the things that we can do; it's in our tool, but normally not until we get into the second stage or thereafter, and the whole point of the treatment is really to try and shift you through the course of this to try and get you towards the end as quickly as possible, and the operation involves trying to release that thickened contracted capsule.

We do it as a day case, so you literally come in just for the day; it's done under general anaesthesia, so you're asleep for it, but we also use a local anaesthesia to numb up the arm, so you don't wake up with any pain at all afterwards. Recovery really takes quite a long time, but urgent physiotherapy is one of the key steps, and really, we're talking about getting things done within the first week of the operation underway.

I was also going to talk about the rotator cuff. As we've talked about, these tendons attach as a cuff to the edge of the ball for the ball and socket joint, and what we do if they are torn depends very much on how this has come about. So, there are two types of tears: the degenerative ones that have come about through time and wear and tear, and the more acute ones, the traumatic ones, that have come off because of a sudden force. People complain of pain and an inability to move it, and some people even describe it as pseudo-paralysis, meaning a false paralysis. They feel that their arm is paralysed, but in actual fact, it's still in working order if we have the torn tendon repaired.

The picture here demonstrates a hole in the tendon at the top, which is the most common terror that we see. It's really the one that helps to take your arm out to the side, and it shows this sort of conic-type tear, but they can come in all shapes and sizes, and the detachment is a particular problem if the one that helps to take your arm out to the side, and it shows this sort of conic-type tear, but they can come in all shapes and sizes, and the detachment is a particular problem if the one that helps to take your arm out to the side, and it shows this sort of conic-type tear, but they can come in all shapes and sizes, and the detachment is a particular problem if the one that helps to take your arm out to the side, and it shows this sort of conic-type tear, but they can come in all shapes and sizes, and the detachment is a particular problem if the one that helps to take your arm out to the side, and it shows this sort of conic-type tear, but they can come in all shapes and sizes, and the detachment is a particular problem if the one that helps to take your arm out to the side, and it shows this sort of conic-type tear, but they can come in all shapes and sizes, and the detachment is a particular problem if it's fully torn off. Unfortunately, the tendon cannot get back down to where it needs to be, and so surgical intervention is the only way to get that tendon back to where it should be attached.

We use a variety of tools to diagnose it. This is a picture of an ultrasound scan. The problem with ultrasound scans is very dependent on the person doing the scans at the time, and although they say they take pictures such as this, they can be quite difficult to interpret if you're not there at the right time. Having said that, it's very good in that it's a dynamic scan, so you move your shoulder around and they can see what's happening when you do the movements, as opposed to an MRI scan, which is very detailed and we can flick through the different images, but it means that you're lying still, so it's a captured picture at the time that you're lying still rather than dynamic, so relative pros and cons for each.

This is a picture of the MRI scan, and it again depicts this torn tendon, so at the top of the ball there is a tendon. I don't know if you can see it here, so this muscle here turns into a tendon that would normally attach this ledge over here, but you can see that the tendon has pulled off and there's a gap between the two edges.

So, treatment options are still involved for potential conservatives. There are people walking outside even now with torn tendons that know nothing about it, so we tend to only see and treat the ones that come in complaining of pain and inability to move. If the tendon has partially torn or is not fully torn, there is still a chance that it will heal itself, so no surgery is necessary, and we can just deal with the pain with the injection side of things or physiotherapy. Surgery may be involved later on down the line if it fails to resolve with those initial treatments. If we do go on to repair the tendon, what we tend to do is have keyhole surgery. Some people are still open to surgery. We know that the outcomes are the same over the long term. It's a day-case procedure, and we tend to take it away. We do a decompression, as explained by Mr Bakti before, to help increase the space for that repaired tendon to move.

The idea is to repair that tender back down to the bone where it should be, but sometimes these tenders, as I said, come in all shapes and sizes and can be torn for quite some time before we get to them, and repair is not achievable. If that is the case, we will talk you through what other options are available to you after the surgery. We tend to keep people in a sling for six weeks while that tendon beds down back into the bone. It's not fully healed by that stage, but it's strong enough to support a range of movement exercises that a physiotherapist will take you through. If we've done it by keyhole, you tend to have only very small skin incisions around the shoulder. I tend to use about four or five, and there tend to be about five millimetres each.

We got a little video here, so this is looking down from on top of the contender. You can see that ceric shape with a red bit of bone exposed underneath it, and the idea is to make some holes in the bone through which we stick little anchors, and anchors are attached to these tapes, which are these blue strands that you can see coming out of them. We then feed those strands through the tendon and then pick them down with two further anchors on the outside, and that brings them across the top of the bone, so these strands are holding that tendon in place. They're not as strong as two further anchors on the outside, and that brings them across the top of the bone, so these strands are holding that tendon in place. They're not as strong as two further anchors on the outside, and that brings them across the top of the bone, so these strands are holding that tendon in place. They're not as strong as two further anchors on the outside, and that brings them across the top of the bone, so these strands are holding that tendon in place. They're not as strong as two further anchors on the outside, and that brings them across the top of the bone, so these strands are holding that tendon in place. They're not as strong as two further anchors on the outside, and that brings them across the top of the bone, so these strands are holding that tendon in place. They're not as strong as two further anchors on the outside, and that brings them across the top of the bone, so these strands are holding that tendon in place. They're not as strong as a normal tendon, but they hold it in the right place to heal over the ensuing weeks.

Three stages to healing After the initial stage of the sling and protecting that area, we start getting some movements going, and thereafter, we start to strengthen the whole shoulder. People tend to return to driving after six weeks, depending on how confident they feel. There's no absolute answer to that, but I would suggest at least six weeks before you go back. You can't obviously drive with a sling, and returning to work again does depend on what type of work you do. In general office work, we say wait until you're out of the sling because commuting can be part of that problem, and manual stuff you should definitely avoid for a few months while that tendon strengthens up.

I’ll hand you back to Mr Bakti, and he's going to talk about bone and joint wear.

Mr Nik Bakti

So, this is my favourite topic. Shoulder arthritis and shoulder replacement are my favourite operations, so there are three x-rays on this slide. The leftmost x-ray represents a relatively normal shoulder joint, and the one in the middle shows arthritis in the shoulder. You can see extra bits of bone at the bottom side of the ball joint, and that represents osteophytes or arthritis. The mouse point is also showing on some loose bodies, and often when it breaks off from these osteophytes, the image on the x-ray rightmost shows what happens if you do not have a rotator cuff and it's not repaired. So what happens is that the balance in the shoulder is gone, the dynamic of the shoulder is gone, and slowly, with time—we're talking about 10 or 15 years down the road—the shoulder migrates upwards, there is no space for the shoulder to move sideways, and often the range of motion at this point is very limited and very painful.

Next slide, please. So, when would you have shoulder surgery? So, I’ve seen quite a lot of people who come in with pain in their shoulders, often quite mild, with terrible-looking x-rays. So, shoulder replacement surgery is only recommended when the shoulder is affecting your ability to carry out the things that you want to carry out, like your hobbies, but it can also start impinging on problem things like putting your clothes on, cleaning, eating, and preparing your food. At that point, if all the other treatments, such as physiotherapy injections, have not worked, then we'll start thinking about an operation. The reason for this is because shoulder replacements are quite a big operation. It can be done by keyhole, but it has to be done open, and it regularly takes about an hour and a half to do the replacement.

Next slide, please. This is just a very quick slide about the principles behind a shoulder replacement. It moves often. You'll hear a reverse shoulder replacement being mentioned, and that's because we change where the ball is and where the socket is in the shoulder to make the dynamics or the muscle balance in the shoulder better.

Next slide, please. So, this is the implant that's used in Benenden. It's the exact equinox shoulder system. It's one of the most common shoulder replacement systems used in the world, with a huge amount of data behind it. This replacement system is very versatile; it can be used for reverse shoulder anatomic shoulder replacements or even trauma, and I think the next slide will show you an x-ray to compare the two.

I’ll tell you about what to expect during a shoulder replacement first. It is not done as a day case, so we expect at least one night stay during the day of your admission. You'll be visited by the nursing staff, and we will see you on the day as well to talk you through the operation again. The operation is done under general anaesthesia because of the duration of the operation, but our anaesthesia colleagues will also give you a nerve block. This involves an injection similar to an epidural, but this is in the shoulder. What does it do? It numbs your arm for about a day or a day and a half. This helps you recover from the gin anaesthetic, and once you've recovered from it, it allows you to then start taking your painkillers before the pain sets in. As I mentioned earlier, most people stay for one night. This allows us to monitor you for pain, allows us to take an x-ray after that, and allows us to see whether you can manage with your arm in a ling. The sling is mainly used in the first couple of days to allow you to get used to getting rid of the nerve block and getting used to your shoulder replacement, and some people can stay in a sling for about a week or so. Physiotherapy is key. Often, patients with shoulder arthritis have severely stiff joints. The replacement helps with movement, but the stretches and exercises that are given by our physiotherapy colleagues are key to helping you get the most out of your shoulder replacement. Again, driving often takes about six weeks onward, but most patients go back to driving after about two and a half months. It's all about confidence again.

Next slide, please. In general, most patients have most of their range of motion back after about one month of active movements, as in movements that you don't need assistance with after about three months. As I mentioned before, at six weeks and golf at three months, most people go back to the driving range before that; it's the nine holes and eight 18 holes a bit later, swimming depending on the style: breaststroke at six weeks, freestyle a bit later at three months, and lightweights can be done quite early in week three or week four, but heavy lifting means manual labouring a bit later between four and six months.

I’ll pass you back to Mr Neen about how much is done in this country.

Mr Daniel Neen

Yeah so we have been collecting data in this country since well for the last 20 years about joint replacements in general we started collecting data about shoulder replacements from 2012 and I thought it was just an interesting little note every year they bring out the new reports from the national joint registry which you'll be asked about I imagine if you come into a hospital to be part of and we have to ask your consent and these numbers are collected yearly and if you look at the number of hips and knees that have been done over the years you're talking about over 100,000 each whereas shoulders obviously very much the poor cousin and we're down at the sort of 6-7,000 mark you see in 2020 all of them took a bit of a dip and that's because of covid and the lack of elective surgery that we were performing at that stage in different parts of the year ankles and elbows obviously are lagging far behind they do have joint replacements but the indications are limited and the technology is still improving shoulders are one of the fastest growing joint replacements currently.

As part of the last report, Just comparing, when they first started bringing out the numbers, 35% of them were only doing hemiarthroplasty, which means we were just replacing the ball, and that was it. They've dropped off to about 5% now because we realised that the outcomes are not as good as we wanted them to be, and you can see that the reverse shoulder and reverse polarity shoulder replacements have much improved in numbers, so we're now obviously about 2/3.

Technology is coming on and on, and Mr Bakti uses it a lot. He's going to talk to you about what we do with the exact tech kit.

Mr Nik Bakti

So, this is my special interest, so I like the use of technology in surgery, not only to help Surgeons but also to help improve the outcomes of finding surgery for our patients. This system that we use from exact tech allows us to marry your CT scan that we get for you before your operation, and it allows us to use it in real time using computer navigation so that we can plan your operation before and reproduce that during the operation.

So, the next slide will just show you the system. This is in real time, so it allows us to accurately plan where we're going to put the implants, and during the operation we will match your CT scan and the plan, and it will allow us to exactly place the implant for your shoulder replacement according to plan. The hope for this is that it gives you a better range of motion, but it is also very useful for patients with very severe arthritis, where there's not much bone in the shoulder or the socket joint, and it allows us to maximise the hold of the screws and the implants that we put in your shoulder to reduce the risk of failure.

The next slide, and I think that brings us to the end of our talk here.

Vicky

Thank you very much, Mr Bakti and Mr Neen. We'll now take some questions, so please leave your questions in the Q&A icon on the screen.

The first one we've got is: if I had a shoulder replacement, would I ever be able to get back to my job, which involves a lot of heavy lifting?

Mr Daniel Neen

Mr Bakti, did you want to?

Mr Nik Bakti

So, I’ll take this one. Yes, the answer is to aim for shoulder replacement to get back to what you need to do. I think it very much depends on what kind of heavy lifting you need to do. So, you know, if it's 50 to 60 kilo stuff, then we have to be slightly sensible and protracted in terms of our outcome, but most of my patients are so amazed by the improvement in terms of function and mainly pain-free shoulder replacement that a few of them said that it's restored their independence and their lives.

Vicky

Okay, thank you very much. Another question is: Does a rotator cuff tear get worse if treatment is delayed or put off? I’m wary of having surgery.

Mr Daniel Neen

So the answer to that one is a bit tricky because it depends on the type of rotator cuff you've got if it's a partial thickness tear then potentially putting off surgery is not necessarily a bad idea at all it gives it a chance to heal itself and so we would employ all those injections physiotherapy and time to see if that doesn't do that on its own if it's a full thickness tear unfortunately there is a good chance that this will get worse with time we know that even the asymptomatic ones unfortunately do become symptomatic particularly if you continue to do activities that potentially rip it further and unfortunately we know that with the full thickness ones because the muscle sometimes isn't able to function as it normally would do it wastes away and it can get to the point that the muscle has wasted away so much that we are unable to fix the tendon all together so it's a bit of a delicate balancing act and it's a good idea to have an idea where you are on that tight rope and I’m sure that a Surgeon a shoulder Surgeon will be able to help you answer that one.

Vicky

Okay, thanks, Mr Neen. The next question is: after a rotator cuff tear is treated, could I go to the gym or lift weights in the future when I’m fully recovered?

Mr Nik Bakti

Do you want me to take this one, Mr Neen?

Mr Daniel Neen

Surely

Mr Nik Bakti

So yes, we expect you to be able to return to the gym and lift weights. Often, there is a spur at the top that can cause an attrition to the tendon, so when we do a repair, we'll take away the spur and repair the tendon, and after a period of rehabilitation, we expect you to return to normal activities.

Vicky

Okay, thank you. That was helpful. The next question is I recently started hormone treatment for prostate cancer and then developed a shoulder problem. Is this likely to be linked to the hormone implants?

Mr Daniel Neen

That's a difficult question. The honest answer I don't know there are papers out there recently talking about hormones and their relationship to shoulder pain per se and they are finding a link testosterone was one that I’ve recently looked into so I know that there is a link most definitely but there it's kind of a something we have to rule out so if we want to know that there isn't any physical damage that there isn't any physical that we can actually repair or adjust for you before we say yep it's down to the hormone replacement side of things so again it's one of those questions where I think bit more information would be useful it's not out of the complete we know the fact that we definitely can't say it's to do with that but I think we just need a little bit more information.

Vicky

Okay, thank you. The next question is from Sarah. Sarah asks, My physiotherapist told me that I have a frozen shoulder. My movements are improving, but the pain is down the front of my arm to my elbow. I’m not sure that the diagnosis is correct.

Mr Nik Bakti

Hi Sarah Thanks for your question. So often, it doesn't have to be an ice or a single problem that's causing a shoulder issue. You may have had a frozen shoulder, and it's good to hear that your movements improved, but sometimes there could be concurrence or other issues that are going on in your shoulder, like inflammation or the tendons, and from what you say, it could even be involving your biceps, so they don't often happen in isolation; they can all occur together, and even when the frozen shoulder settles, you may have ongoing issues. So, if you're worried, come and see one of us, and we can have a look at it.

Vicky

That's great advice. I think that's helpful. The next question is from William. William asks what type of shoulder pain you would expect with the various conditions you described. I have shoulder pain that extends down to my fingers. Would this indicate some of the issues you have described?

Mr Daniel Neen

Absolutely yeah so surprisingly people do get referred pain and the pain can literally go down to the fingers with shoulders it's unusual but people regularly describe pain going down the outside of their arm halfway down their arm and this is a classic referred pain that it's all to do with the nerves in the shoulder and where they innovate and so although the problem is at the top of your shoulder it actually feels like it's coming halfway down your arm on the outside it doesn't just stay there though sometimes people do talk about it emanating down to the elbow even down to the wrist and on rare occasions into the fingers if it is into your fingers we be more likely to think that it is related to nerves potentially and there are various causes of nerve issues related to the shoulder or even further up towards the neck that can emanate down towards the hand and so diagnosis wise we'd have to do a proper history and examination Frozen shoulder is a classic one for this jerk-type pain, so somebody would suddenly try and do something such as catch something that's falling off a table, and they would describe this intense burning sensation in their shoulder that lasts for about 30 seconds to a minute before dying off. Impingement typically is a pain on the outside of the arm with movements going out with your elbow going out sideways or reaching up above you.

Vicky

Okay, thank you, Mr Bakti. The next question is from Ben, and Ben asks, What are your thoughts on hydrodynamic distension in the treatment of frozen shoulders?

Mr Nik Bakti

I’m a great proponent of this, and I think Mr Neen is as well.

Mr Daniel Neen

Yes, absolutely.

Mr Nik Bakti

It is one that is performed by our radiology colleagues, so our x-ray colleagues do it under x-ray or ultrasound guidance, and in most circumstances, and maybe in two cases, it helps significantly with not just pain but also movement.

Vicky

Thank you, Ben. Next is from Gavin. I’ve had an x-ray and been told I have arthritis. Do I need other scans to establish 100% that it is only arthritis issues I have and not something else, such as a tear?

Mr Daniel Neen

Sorry to hear about the arthritis. I would suggest that an x-ray is adequate to diagnose the arthritis itself. We can see typical changes on an x-ray for arthritis. The reason for further scans will really have to do with planning any further treatment, so as we've alluded to, there are two options. If you were going down for shoulder replacement, for example, you could either have an anatomic if all your tendons are attached or a reverse shoulder if there is any damage to the tendons. First of all, an ultrasound scan or an MRI scan will help tell us that for sure, so there's no guesswork involved, and then to plan the actual replacement itself, a CT scan would be used. A CT scan is basically like a glorified 3D x-ray, and it gives us far more detailed information about the bone structure. We can plan the sizes and positions of all these implants that we could potentially use, so an x-ray is good, but we can use other things to give us further details.

Vicky

Okay, thank you. Anonymous asks, Do you have any statistics on the success rate for shoulder replacements?

Mr Nik Bakti

So shoulder replacements have been around for quite some time and as you as Mr Neen mentioned earlier we've been keeping data on them since 2013 so yes they do well for the right problem so for arthritis for patients with chronic rotator cuff problems with movement issues that is not repairable then they do really well they predictably manage they reduce your pain very well movement often 90% improvement in movement but of course no operations without risks and I think it's all quite individual so if you do think that you have shoulder arthritis that requires shoulder replacement I think it's best that we examine you investigate how bad the problem is and we can discuss the pros and cons of the risk and benefits of a shoulder replacement.

Mr Daniel Neen

I think in terms of the reverse shoulder in particular, the results are extremely good. 15 years, so it's a relatively new technology, reverse shoulders, but we're on our fourth or fifth generation of changes now, and the longer-term follow-up is starting to come through, and so 15 years plus of follow-up have shown extremely good results of over 90% success and satisfaction, and for that reason, I think the number of reverse shoulders being used now is growing and growing because we have that faith that it does a good job in the longer term.

Vicky

Lovely. Thank you both very much. The next question is from Francis, who asks I was diagnosed with severe shoulder osteoarthritis last year. For the last four months, I’ve had physiotherapy, but I’m still in pain with reduced movement. How do I know if I need a shoulder replacement?

Mr Daniel Neen

Mr Bakti, do you want to?

Mr Nik Bakti

I think yes; I don't mind taking this one, Francis. I think the best way forward is through some form of imaging, so most simply, it's an x-ray that will confirm if you have arthritis or not, and based on that, if you do have arthritis, we can then discuss, based on how much limitation in movement and pain you have, whether you are a good candidate for a shoulder replacement.

Vicky

Thanks, Mr Bakti. I have time for a couple more questions. So, Robert asks, I’ve been diagnosed with joint diffusion around the biceps tendon and capsulitis. I’ve had four steroid injections over the past 30 years. Massage helps, but I should think about physiotherapy before asking about surgery to deal with discomfort rather than pain.

Mr Daniel Neen

I think that physiotherapy would be a very good starting point. I think you've obviously had quite a number of steroid injections. If I see somebody with sort of this diagnosis, I would tend to suggest one or two injections just to help with the diagnosis and to see if that calms the situation, but if it keeps coming back, then I think that I would talk about a more permanent solution, and there are things that we can do for the bps tender specifically to stop it having this problem. Having said that, Phylis, if you've not had any physiotherapy at all, it could be worth trying just to see if they can get the muscle balance and to make sure that if you're doing something specifically that's agitating, is there a better way of doing it?

Vicky

Okay, I hope that was helpful for you. The next question is from Vivian, and she says that her shoulder pain came on quite rapidly about 10 weeks ago. She gave it about six weeks before going to the doctors who referred her to physiotherapy, and she has her first appointment through Benenden tomorrow, but the pain is getting worse instead of better. She's been using ice and recently heat as well, but that's causing pain even when sleeping. She asks, Do you think I should insist on a CT or MRI to find out what's happening? I’m concerned that waiting could result in a more serious issue, and she also adds that she's a horse rider who's very active but currently very limited in what she can do, worried that the pain will be life-limiting if she doesn't get it sorted.

Mr Nik Bakti

Hi Vivian, I think giving it some time to see if it settled was a very good idea. The fact that it hasn't settled means that you probably need some help. Surprisingly, physiotherapy and my physiotherapy colleagues are very knowledgeable; they might be able to give you a better idea of what the problem is, and with the exercises, we've seen amazing results, but the fact that you had no problems with your shoulder 10 weeks ago means that if physiotherapy and conservative treatment don't help, then I feel that between a CT and an MRI scan, an MRI scan will give you a better idea. If it's appropriate, a CT scan like what Mr N mentioned earlier is a glorified 3D x-ray, and often MRI scans give us a better idea of what's happening around the shoulder and the structures around it.

Vicky

I hope it's helpful for you, Vivian, and yes, best of luck with your treatment. The final question is from Jasper, and he asks, Could you please tell us what the future of robotically assisted shoulder replacements is shaping up to be? What are the upsides and downsides? Can they lead to muscle waste? Strength?

Mr Daniel Neen

Wow, okay, so I mean, Mr Bakti normally deals with all these technological questions, but my take on robotically assisted shoulder replacements is that they are definitely coming. It's not a question of if it's when they have recently started knees and hips around this region and I know we have a robot here in Benenden now to help with the knees and in essence what it appears to be doing is helping guide the Surgeon in during the operation itself as to where to make the safest cut and how to direct the bits and that they can't see within the bone with our GPs system that we use with exact tech it does pretty much the same sort of thing it's guiding your hand as to where you want to be drilling and then putting the screws it can tell us how deep the drill is going and the whole idea of it is really to increase the accuracy of where we put these implants with the vision that longer term this will give you the best optimum outcome. The evidence for it is not 100% yet in terms of one or two degrees of accuracy actually equating to a better clinical outcome, and shoulders are lagging behind. I understand that in America they are now starting to do these first robotically assisted shoulder replacements, so it'll be some time before it comes over here. But I think yeah, onwards and upwards, I’m all for it. The only problem I can see is that if people become so reliant on robots during an operation that one suddenly stops working, what do you do?

Mr Nik Bakti

So, I echo Mr Neen's comments. Actually, I think last week the first robotic shoulder replacement was done in America, and like Mr Neen said across the pond, we are a few years behind, so my opinion about all of this is that, just like the GPs system, it improves accuracy, but whether it changes clinical outcomes we don't know. But where I think it's valuable is in complex or severe shoulder arthritis where there's very little bone to play with or there's very, very little leeway where we can place our implants. That's where the benefit of the robotic or navigated shoulder replacement is, and we're seeing more and more of this, I think. Do you agree, Mr Neen?

Mr Daniel Neen

I do, yeah, absolutely.

Vicky

Lovely. Thank you both for that good one to end there. So thank you to everyone for your questions, and I just wanted to let you know that as a thank you for joining this session, we're going to be offering 50% off the value of your initial consultation, a call back from your dedicated private patient advisor, and an email tomorrow with the recording of the webinar treatment information and loyalty reward points that you'll get for attending this webinar, as well as updates on news and future events. We'd be really grateful if you could complete the survey at the end of this session to help us shape future events. Our private patient team can take your call until 8.30 this evening or between 8am and 6pm Monday through Friday using the number on the screen.

Our next webinar is on treatment for hip osteoarthritis, which you can sign up for on our website.

On behalf of Mr Neen, Mr Bakti, and our expert team at Benenden Hospital, I’d like to say thank you very much for joining us tonight. We hope to hear from you very soon. Thank you, and goodbye.