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Watch our shoulder surgery webinar

Consultant Orthopaedic Surgeon, Mr Daniel Neen, discusses treatment options for common shoulder conditions and injuries.

Please note that any discounts advertised in this video are exclusive to attendees and registrants of the live event.


Shoulder pain treatment webinar transcript

Phil Orrell

So, a very warm welcome to our webinar this evening and this session will cover shoulder pain treatment and surgery. My name is Phil I’ll be your host for this evening, and I’m joined by our expert speaker Mr Daniel Neen who is our consultant orthopaedic surgeon here at Benenden Hospital.

Just to give you an overview of the format of the session, a presentation will be around 40 minutes, and this will be followed by a Q&A session. You can submit questions for Mr Neen at any point during the presentation and you can do this by clicking the Q&A icon at the bottom of your screen and you could submit your questions anonymously or you can provide your name and I should let you know at this point that if you do provide your name we are recording this session if you would like to book your consultation we'll provide you with contact details at the end of this session that is quite enough talk from me I will hand over now to our Consultant Orthopaedic Surgeon Mr Daniel Neen.

Mr Daniel Neen

Thank you very much Phil, good evening, ladies, and gentlemen. Thank you very much for coming in to join us today. So, as phil said my name is Daniel Neen one of the surgeons here at Benenden Hospital and this evening I’ve been asked to talk a little bit about shoulder pain treatment and the surgery we offer here at Benenden Hospital.

So to start off with I guess you want to know a little bit about me I graduated from London in 1999 and trained in the southeast region and as a registrar and then went on to do some sub-specialty shoulder and elbow and wrists and hand fellowships at in Exeter and also in New Zealand and then became a consultant in Dartford in 2015 and then was made substantive thereafter starting in Benenden the year after that interestingly when I first started so not that long ago really I guess in the grand scheme of things reverse shoulder replacements which is something that we will be talking about later on in this talk wasn't actually being done in the Dartford hospital and at this stage this has increased and increased and so my colleague Mr Bakti who also works here at Benenden and myself we are now approaching 50 to 60 replacements a year between us which is above the national average.

So what we'll be talking about obviously it's always useful to know about the shoulder itself and I won't go into too much detail about it but there are some key terms that people usually hear about the shoulder and the attachments around that area we'll talk about the anatomy and the rotator cuff is one of those names talking about the reverse shoulder but we'll talk about a gentleman called Paul grandma and his philosophy and what that brought we'll talk a little bit about common shoulder pains and injuries and the treatments that are on offer for these typical problems that we encounter frequently and these things include rotator cuff repairs surgically joint replacements and then the non-operative aspect of things such as the physiotherapy and steroid injections. At the end as phil mentioned we'll have a question-and-answer session but nothing too difficult.

So shoulder problems shoulders are actually a very common problem that we encounter in the UK at any one time 14 out of 100 people will have a shoulder problem second only to really to backs every year about one or two people will out of 100 will present to their GP with a new type of shoulder pain and most of this is coming from the soft tissue element of the shoulder itself so the rotator cuff the rotator cuff is a series of tendons that attach to the rim of the ball and socket the ballpark that we call the humerus the humeral head and these help to rotate the shoulder the idea of the shoulder is I do is put your hand somewhere in space that you can actually use it to do something useful so here we go it's a medical school some basic anatomy the long arm bone we call the humerus which isn't very funny at all the shoulder blade we call the scapula the little ledge of bone that you can feel over the top here which is actually part of your shoulder blade called the acromion and that has a joint right next to it with the collarbone that we call the clavicle and so in fact there are two joints in the area there's the ball and socket with the head of the humerus and the shoulder blades scapula as well as the joint above between the collarbone and that ledger bone the acromion.

If you imagine that the ball and socket well the shoulder itself is a very mobile joint far more mobile than say the hip which is also a balloon socket and the reason for that is that the bony anatomy allows that great range of movement the problem with it is that the actual sockets side of things if you imagine it's like a golf tee and so that does mean that the joint itself is inherently unstable and so to rely on just the ball just the bone itself would mean that we'd be dislocating the shoulder left right and centre so what we do rely on are the ligaments and they're the sort of belt straps if you like that attach bone to bone as well as the tendons and the tendons are the things if you imagine they're like pieces of string or rope that attach the muscle that does the moving side of things to the bone.

So here we have the ball and socket and the thing I was going to point at going around the structure here is the biceps tendon you actually have two of those tendons hence the word bi with some ligaments that are attaching the shoulder blade to the rest of the the collarbone and the acromion above building up on top of that we then have some ligaments at the front here that we can see and built bit by bit we build up these soft tissue barriers to stopping the dislocations that we occur there is an important structure just the front here that attaches to the front called the subscapularis that tendon is responsible when it pulls it takes your arm behind your back at the top there is a tendon that attaches to the top here called the supraspinatus and that's involved with lifting your arm out to the side and then around the back is the infraspinatus and that's involved with taking your arm out to the side and and externally rotating it as we call it and together they merged to form this cuff of tendons.

The problem we had previously before this gentleman was that one of the issues is that the tendon at the top tends to tear and that can be as a result of trauma directly ripping it off or as we get older just as our hair starts to turn white the tendons themselves can start to peel off and with losing that ceiling if you like to the top there you'll you become very reliant just on the big muscle on the outside this bit here we call that muscle the deltoid unfortunately as you can see there's quite a wide arc of movement and so when the muscle contracts it's pulling the arm bone directly up into the the shelf here the acromion and so you get a levering effect and so before Paul grandma's theory came along we were left with treating the pain or if we wanted to try and repair it we used to do shoulder replacements that looked exactly the same either we've replaced the ball with a piece of metal or the ball and a socket with a piece of metal and plastic but you'd still have the same issue with that deltoid muscle pulling it up and wearing away causing pain so poor grandma on this French surgeon came up with an idea back in the 70s it appears but it didn't actually publish anything until the 80s about reversing the biomechanics of the shoulder and created something called the reverse shoulder and as we can see in the picture here when he basically did was turn the socket into a ball and the ball you chop off the top half of that and turn that into a socket and realign that underneath so now when that big muscle pulls up instead of shunting the ball up into the acromion you would get a movement you become far less reliant on that supraspinatus tendon to hold it down into place.

These tendons all merged to form a rotator cuff as I said and it's not just the supraspinatus which is labelled here and attaching to the top hinge it can be the subscapularis it can be the infraspinatus there is a smaller tendon just at the back here as noted here teres minor which also comes to help with the external rotation side of things and and any and all of these can be affected with this tearing phenomenon and the problem with it comes that once it's torn off there is no real way of that tendon finding its way back down onto where it came from if the tendon is partially torn then there is a a way of it healing or scarring up which is what a lot of people ask about is it possible to hear unfortunately if it's pulled off altogether then there's no real way of it coming back down to where it should attach unless we surgically go in there and try and fix it back into place we do that with little pegs that we bury into the bone out of which comes string or we call suture that we suture through the tendon and then anchor it back down onto the bone and those sutures are really just putting that and holding that tendon back into place where it should be while the bone heals back on and that process takes somewhere around 12 weeks in general during which time we have to protect the repair.

We talk about the rotated coffee in terms of force couples and this is why it becomes very important to repair these tendons sometimes because if you have one side that's torn off and not the other side and you can imagine that golf ball on the golf tee or the head on the glenoid as the analogy goes will be pulled in one direction in particular and gradually would wear the joint in that one direction. By and large it is the supraspinatus at the top though that participates in these rotator cuff tears. We call it a rotator cuff arthropathy and when the ball heads up underneath that ledge of bone so for the simple reason arthropathy just means bad joint and the rotator cuff tear is the underlying reason as to where it's ended up why where it is what we can see here is that the ball and socket the ball is headed right up underneath this ledge here with minimal room whereas there should be quite a good gap between the two bits of bone we can also see that there's arthritis here arthritis itis on the end of anything just means inflammation and off means joint so there's inflammation in the joint from the cartilage that has been worn away we can see the bone is rubbing on the bone there whereas again normally there's a gap on the x-ray the gap is not a true gap it's actually cartilage but cartilage doesn't have calcium in it and therefore doesn't show up on an x-ray cartilage itself doesn't have any sensation and so as the cartilage is being worn away in the process of arthritis it doesn't it's not particularly sore it can have a little bit of discomfort maybe or stiffness gradually in creeping in day by day but in general it's not until that the bone is exposed that you get the typical arthritic pain which is a constant gnawing pain worse with movements and can't even wake you up at night with this particular type of arthritis or the joint rotator cuff arthropathy you have these two surfaces involved so not only do you have the ball involved you also have the under surface of that acromion or leisure bone there from the shoulder blade and also the socket joint here causing pain.

Shoulder pain shoulder pain is a common problem it certainly is related to as we get older and our joints start wearing out it can be related to this arthritis that we just discussed dislocations obviously cause acute pain and usually mean that you're going to a e because you can't move the shoulder at all all of a sudden after a four the actual shape of the shoulder itself will look different as well you usually have the squaring as we call it where there's a sheer drop at the edge of the shoulder instead of the normal round shape you have a literally a flat edge rotator cuff damage again is usually associated with trauma acutely but it can be a gradual aging issue with certain sports particularly contact sports you can have acute injuries repetitive movements from jobs that we do particularly those that involve overhead repetitive movements and I see that a lot in plasterers and electricians for example and then there is something called frozen shoulder and I’ve seen that increasingly for some reason over the last few years now a frozen shoulder is in essence a soft tissue issue the joint lining becomes inflamed the lining is the thing that keeps all the fluid in and and literally lines it away from the tendons overlying it now that becomes thickened and inflamed and gradually the movements are lost as well so it can be coming on from no reason at all it can be from a little jolt or a little form to something that you wouldn't even think twice about such as a dog suddenly running away and pulling on the lead that you were holding and it's not necessarily straight away it can be coming on in the following days or weeks with a gnawing pain that it starts off and then gradually turns into a stiffening of the movements the good news about that frozen shoulder is that there is a light at the end of the tunnel it will get better on its own if left long enough but that time can be up to two years and there are things that we can do to try and shunt you along that course or process quicker.

So depending on what is causing the pain there are various things that we can do here at Benenden to try and help mitigate it and obviously a reverse polarity shoulder replacement or an anatomic which is where we replace ball and socket like for like if the tendons are all intact it's something that we can offer here rotator cuff tears are done routinely week in week out to repair those tendons back to where they should be to help with the function.

Obviously it's not just the rotator cuff there are other tendons around the area such as the tendon or the biceps tendon that we can help fixed back into place frozen shoulders as I said there are a variety of things we can do from injections into the joint of a very strong anti-inflammatory to keyhole release of the shoulder so that helps with the range of movements straight away.

These are all things that we can talk about the pros and cons and relative risks involved in each of the decision-making process arthroscopic subacromial decompression is quite a mouthful in essence it's shaving away the under surface subacromial so the under surface of that acronym that ledge there and the reason that we would do that is if there was a little spur of bone that we do see quite frequently causing damage to the underlying tissue or irritating it further imaging such as an ultrasound scan or a simple x-ray can demonstrate that spur quite nicely if there are loose bodies such as bits of cartilage and bone that have broken off in the process of a trauma or of wear and tear they can jar in that ball and socket and cause issues and we can remove those through the means of keyhole surgery the arthroscopic bit and of course underlying all this there is a strong physiotherapy guideline that by and large an awful lot of these shoulder problems can be treated initially with the physiotherapy and avoid the surgical side of things altogether.

Ss previously discussed when we come to this rotator cuff repair which is one form of surgery we we aim to pull the tendon back down onto the bone in general we do this with our anaesthetic colleagues under a general anaesthetic so you're asleep for the operation it's just a day case so you're in and out of hospital in the same day and they do tend to offer you a nerve block and a nerve block is in essence an injection into the base of the neck where all these nerves come out of the neck to go down your arm now that may sound horrific and in general it used to be done with just landmarks so we used to measure how long your collarbone was and halfway down halfway up hang the injection and then wait until it hits the nerve and makes it go numb but these days obviously things have moved on and on and on and it's far safer and they use an ultrasound probe to look at these nerves specifically and then aim the local anaesthetic medication around the nose not into them this means the damage from a nerve block itself is far less but you still get the amazing relief that a nerve block gives you so you wake up from your surgery without any pain at all one of the side effects of having a nerve block is that you cannot move your hand as straight away and that's something that we will talk you through afterwards but that pain relief is a key principle because it although it's only a minor keyhole surgery as some people's talk about it the actual amount of operation operating that goes on inside the shoulder is quite considerable and it hurts and so yeah the first 24 hours of that nerve block is is usually very beneficial.

Depending on what we do you usually wake up with a sling and because we want to protect that repair the tendons being repaired we protect it in this link for six weeks that's not to say that you have to wear that sling all the time for six weeks you can take it out to stretch out that elbow because we definitely don't want that to get stiff same for the hands and the fingers but by and large we want to keep that elbow by your side and not using the shoulder to do everyday activities straight away because even that sort of minimal force such as picking up a kettle can potentially damage that repair initially the key the beauty of the keyhole surgery however is that you only have a few small skin wounds that heal within the first 10 to 14 days and we use stitches they they come out at that sort of time period and depending on how big that rotator cuff tear repair is depends on how many of these small incisions and they're literally usually just a width of a scalpel blade so we're talking about four millimetres each with a main eight millimetre hole just on the side for the main working hole.

Physiotherapy is a principal treatment for a lot of shoulder conditions obviously if there's a rotator cuff tear it won't repair that tendon back down again but there is some evidence out there that not every tendon needs to be repaired and so again this is something that one of my colleagues or myself can talk you through as to whether or not you have one of those conditions that needs an operation however physiotherapy and they're very good at getting things moving correcting posture issues that can be at the core principle of why you've got or developed an issue in the first place and then trying to rehabilitate the muscles that help rotate and move the shoulder a lot of these muscles waste away relatively quickly without use and it's very difficult to move it if you have pain and so you get into this vicious circle and so that's where the physiotherapists come along and really help matters with the exercises that they give you and the general toning up of the muscles around that area as best they can.

Shoulder replacement surgery so never say never and we can't blanket everybody with arthritis needing an operation that's the key principle of this surgery I see it as a very last resort if if needed at all there are a few indications where surgery is definitely to the benefit and we would go in there sooner rather than later but by and large most things physiotherapy pain relieving steroid injections first before we end up having to come to the surgery side of things and arthritis is a very similar process to this and that we diagnose the arthritis and then you have a stepwise progression towards an operation not necessarily diving into it straight away and the things that we we tend to do is one is to educate try and get you to understand why it is that you have the pain in the first place and what this arthritis business is all about there are things that you can do in everyday activities modifying what you do or doing it in a slightly different way to help prevent the pain painkillers we can discuss but by and large your general practitioner will be guiding you through the the basic painkillers and then working up what we call a pain ladder so you gradually get stronger and stronger painkillers the anti-inflammatories tend to be the better ones for muscular skeletal issue but not everybody can take these and again we've got to be a little bit careful about how often and for how long you're taking these courses of anti-inflammatories once it starts interfering with your quality of life preventing you using your muscles keeping you awake at night so sleepless nights are a very big indicator of how bad that or how severe the pain is those are all sort of key statements that we're looking for in your history when we talk to you that indicate well maybe you've progressed through all the things that we can do without an operation and that really now is time to replace those damaged joints.

We've mentioned a reverse shoulder replacement focusing very much on those rotator cuff arthropathies that we see a lot of and by and large I would the majority of my shoulder replacements in people over the age of 70 would be the reverse shoulder replacement and even in the cases where the rotator cuff tendon may be intact it's for seeing what will happen in the next five years because we know that if we do an anatomic replacement that potentially they would fail once the rotator cuff fails and so it's trying to balance out what's good for you now versus what's potentially going to happen around the corner but shoulder placements can be this anatomic replacement whereby you are replacing like for like so you're replacing the round surface of the ball off the top of the humerus with a round metal cap that can be with a stem as well and that stem goes down inside the bone or in this case as the photo on the right shows a stemless which are coming on and on these days with the evidence showing that they are very good.

Then on the socket side because that also is going to cause pain we replace that surface with a plastic joint and again on the picture on the right side there although you can't see the plastic because once again it doesn't have anything that shows up on an x-ray you can see these metallic pegs that are on the back of the plastic and they just mark as an indicator where this plastic socket is sitting. This anatomic relies on that rotator cuff to be intact and fully functioning.

As we've talked about that reverse shoulder that ball is riding up there on that picture on the right right under underneath the acromion rubbing bone on bone and we can see a little spur of bone on here so the round ball is no longer perfectly round and in these cases where there's definitely no tendon on top here because there's no room for the tendon it's literally bone on bone we would go for this reverse shoulder geometry and this is a typical picture of the type of implant that we use here where there is a metal base plate that we secure into the scapula the shoulder blade with a central larger peg that is filled with bone and then usually four screws that also secure it so it doesn't rock so much and then on top of that base plate we place this cap that we call a glenosphere which is basically half a globe secure that into place and then on the other side you've got this metal stem that goes down inside the tube of the the arm bone the humerus on top of which lays a metal tray and we secure that with a screw and then in between the two again that you can't see but the secure to this tray is a as a plastic insert and that helps to stabilize everything.

This is the equinox shoulder system that we use here at Benenden myself and Mr Bakti use this it's by and large is uncemented meaning that we don't use the usual grout that people use in other hip and knee replacements in the past and in essence we're relying on the bone growing into the metal to secure it in place in the longer term.

There are various designs that have gone through the process so since grandma's first design of a reverse shoulder this is now almost the fourth generation that we're using as the designs tweak if you like different angles different geometries different ways of fixing and bit by bit it's it's gradual process we're very lucky in this country and that we have this national joint registry and I’ll come back to that in a little bit so with shoulder surgery you come in either early in the morning or later on in the morning if it's an afternoon list you'll be seen by the nursing staff who run through a checklist with you provide you with your gowns change into we then have the anaesthetist and the surgeon come and visit you beforehand to make sure there are no further questions to make sure all the last minute check boxes have been tipped you have this general anaesthetic with a nerve block in general you don't have to have the nerve block that is just offered to you and then this will go through exactly the pros and the cons and the risks involved but as I said in general it does mean that you wake up with no pain and these days is becoming increasingly safe shoulder replacements themselves there is a a move to try and bring them into a day surgery scenario but that's only for a very select few patients that would be first on the morning list so to speak because there are a few check things that we have to do after shoulder placement one being a routine blood test two is an x-ray and three we have to make sure you're comfortable and able to go home before we send you home and so it tends to be an overnighter and then going home mid-morning the following day your arm isn't a sling until it's waking up from the nerve block so to help protect it from swinging into doors and all those being trapped in places you don't know because you've got no control over it then you can't feel it it doesn't hurt as it would normally would do so it's it's very important to keep it protected for that first initial period and then the physiotherapist will guide you as to how you can win yourself out of the sling over the first four to six weeks.

So everybody's different in terms of their rehabilitation but in general we can go through what we what we expect to be even normal so in general as it says here by week three you should be getting up to 50 what you were doing beforehand bearing in mind that your shoulder would have been very stiff anyway usually because of the arthritis by the six week mark passive movements which the physiotherapist would have helped you with and would have shown you how to do yourself to a degree would be up to where you were before the operation and then active movements at least the pre-op level by week 12. So you can see it's it is a lengthy process in terms of healing in terms of movements and and being active but in actual movements to to get out of a sling you're doing that very early from weeks one and two driving you're safe to drive we say from week six when we normally see you for the first follow-up surgically but that it does depend on how confident you feel and my advice is always to sort of sit in a stationary vehicle with the engine on and see how you would cope automatics obviously easier to cope with in a manual but that's not to say that a manual is not possible all steering wheels obviously these days are pretty much power so we don't have to worry about that anymore golf golf seems to be an important question and a lot of people ask about a goal and I would say that normally yeah from week 12 you can go back to a driving range and see how you fare from there swimming again we've got to be careful about what type of stroke that you're going to be using and free staff certainly I wouldn't advise before 12 weeks but you can go back to doggy paddle and breaststroke from week six easily.

Lifting again you've got to just be careful and a bit of common sense you've had a major operation here and things are healing and the body does take time it takes longer than a lot of people think to heal the soft tissue bones were used to fractures okay six weeks and and things are going again but for soft tissues ligaments it can take a good three months and so we've got to go a little bit steady with these things.

In terms of volumes of joint replacements that are done we have this thing as I mentioned earlier the joint national joint registry we're very fortunate in this country to have that and we're the biggest joint registry in the world pretty much Sweden and Australia are also good at collecting their data and it's only from collecting large numbers of these different prostheses that we do and seeing how they follow that we can actually see which ones are good and identify which ones are failing earlier and choose to to narrow down the spectrum of choice that we have in terms of which implants to use for the betterment of our patients so hips and knees obviously are well established and you can see the sort of numbers in the UK that we are doing prior to covid and then in 2020 covert hit and you can see that elective surgery obviously took a big tumble and then we're starting just to pick up now from the pre-pandemic levels really but you were talking about a good hundred thousand plus of each type of replacement their shoulders we've been collecting data on in this country since 2012 and the the technology has improved and increased and again significantly fast fast increasing but nowhere near the same sort of numbers as the hips and knees which are well established obviously ankles and elbows the indications fall more narrow and the implants being implanted in this country are far less.

In terms of type of registry I think it's quite interesting looking at the development so this gives you an indication of our technology back in 2012 when we first started collecting this information for shoulders 35 so a third of the implants being put into people were hemi arthroplasties what does that mean it means only one half of the joint was actually being replaced and that half was the ball for the ball and socket so people would still be left with a potentially painful glenoid socket and potentially if there was a rotator cuff tear then this hemiarthroplasty would still be doing exactly the same thing that your original bone i.e. riding up underneath that a chromium and the metal would then be rubbing away against the bone instead of the yellow bone so hemi arthroplasties have quite a mixed bag of results in terms of what they've been used for in the past and the outcomes and I think that's where shoulder replacements got it quite a bad name for themselves initially at that stage only a quarter of the replacements were being reversed and I think that's an indication partly of training to be honest and partly of we're unsure as to the longer term results we don't want to stick these pieces of metal into people where we don't know how long or where it's going to go in the future over the years technology as I said we're on to the fourth generation of implants now and we're starting to get the longer term results back from these newer versions and increasingly we're putting more and more of these reverse shoulders in and less and less of the hemiarthroplasties the total shoulders the anatomic ones where the ball in the socket remain the same are staying about the same about a quarter of the patient patients having that type of procedure but it only seven percent so less than one in ten having the hemiarthroplasty and that's usually a younger patient after a trauma so in reverse and interesting I was just a an international course last week and they were stating that 90 of the shoulder replacements they were putting in these days were reverse shoulders so again I think that's testament of the outcomes that are coming and the good results that these reverse shoulders are giving us.


Use of technology has come on and on and in Benenden we have this particular app that comes with our implant that we use and what it allows us to do and there are other incline companies that have a similar application you can import a CT scan which then builds up a 3d model of your particular shoulder blade and what we're looking at here in particular is the socket and from that socket we can then decide on what type of replacement we are going to use either if it's going to be an anatomic or reverse we can choose the angle it goes in at we can choose the size that we're going to use and we can look for any potential pitfalls that might trap us at the time of surgery so in other words it's a form of planning that we now have that we never used to have and we certainly cannot plan to this sort of detail on a plain x-ray.

Phil, I believe it's now back to you.

Phil Orrell

Thank you Mr Neen some excellent insights there into the various conditions and the treatments that we can offer for them here at Benenden moving on to questions from our attendees so the first one is with a reverse replacement will I regain a range of motion similar to what I had before my injury?

Mr Daniel Neen

So that's a very interesting question so reverse replacements when they say injury I presume that they've torn their rotator cuff and so or they've had a severe fracture and so the fracture itself is not repairable and in that case scenario then we we are looking towards reversing more and more we're using a reverse as a first line treatment so so I’ve got some good news and bad news from that point of view the good news is that we know that doing a reverse replacement straight from the off gives you a much better outcome than if you have a fixation that then subsequently fails and then you have the reverse shoulder it gives a very reliable outcome and it's a good pain relieving operation with a degree of function as well and I say a degree of function because if you have come from an area of normality I you were walking around doing everything you were doing normally before hanging out washing or lifting things out of cupboards above your head and all of a sudden you've fallen over and you've had this severe trauma to your shoulder unfortunately it will never be the same again no matter what we do and so what we're trying to do is optimize the outcome in the longer term shoulder reverse shoulder replacements the geometry is different to your ball and socket so we are lengthening that muscle on the outside and you'll have a squaring off of the shoulder it won't look the same however the function is still pretty good you'll still be able to reach up above your head with your hand you will still be able to reach things down from covers the pain hopefully will be taken away and diminished the rotation is the thing that I think most people notice the most and that's again because the geometry if you imagine the tenders at the front pulling in that direction are now angling downwards because everything has been lengthened and so their pull is not in the same direction so the rotation going out sideways is definitely not as as it was as a normal person I’m going up behind your back is also limited and normally we aim for just above the buttock region the small of your back and then going out sideways I’d say 30 degrees something to aim for maybe 45 degrees and usually you have one of more than the other depending on how it's been put in.

Phil Orrell

Okay, thank you. the next question is I have mild shoulder pain but not from an injury it causes me to have poor sleep some nights but otherwise I can do most things at what point would you suggest seeking help?

Mr Daniel Neen

Yeah okay so mild shoulder pain with no trauma but is interfering with significantly with with sleep potentially was that yeah so night pain is always something that we are looking out for in the history so first of all you know you start thinking about well what could be causing pain in the shoulder area and there are a number of things locally so it could be bone it could be tendons could be ligaments or it could be referred so it doesn't necessarily have to be from the shoulder it could be from a nerve such as coming out of your neck so all these different things that can cause pain in the shoulder region and teasing out what is causing what is part of the history taking examination that you need in terms of when to do it well like all these good things if you've got pain there is something that your body is trying to tell you is not right and so if it's associated with some particular aspects of of your life such as weight loss or you your appetite's gone down then it's certainly something that I wouldn't wait around I would certainly have a discussion with your general practitioner sooner rather than later if you think you can attribute it to doing something you've you've had some exercise and then it's come on a few days later again normal normally if these things sort themselves out within a couple of weeks maximum and if it's going on beyond that then really again I would seek some medical help and just to go through the finer details of what this pain is like so I wouldn't sit on that sort of thing though.

Phil Orrell

Okay, thank you. next up we have a question from Andrea this is quite complex so bear with me both my shoulders are subluxated I have left glenohumeral and a c j o a an early glenohumeral on the right I swim regularly I’ve had high hyaluronic acid injections into both shoulders with improved symptoms I have a cyst in the socket on the left about the size of a 50p my rotator cuff is intact but with signs of tendinopathy it's supraspinatus I was told that I would need a shoulder replacement within five years that was almost five years ago I cannot sleep on either side what should be my next steps?

Mr Daniel Neen

Well it sounds like the plan has already been put into process if if you're having sleep affected and it's gone for that stage and we know that there are degenerative changes i.e. arthritis of both shoulders then it is at the point now where you can certainly I would explore the the nuances of a shoulder replacement at this stage be it a reverse albeit an anatomic I know that she said that the cuffs were coupling was intact but there is still a case for a reverse children some people even in that situation however what the idea of this whole process is to get you out of pain so it's a pain relieving operation increasingly these days function as a secondary phenomenon is improving and the exact tech that we use now along with that app that I showed you where we can predict what type of implant we're going to be using they also have a model called predicts plus which is we can input the data of how bad the pain is and what limitation of movement they have to to predict what they are going to have after an operation and it will literally print out a form saying three months six months two years what's the pain is going to be like and what the range of movement the function of the shoulder should be like as compared to all these thousands of people that have had the operation beforehand and they match it for your age and match it for your sex so I think that's a very useful way of thinking about whether or not you should go ahead with a shoulder replacement because it on top of that you have to think of the risks and I guess this is what everybody thinks about these days quite rightly is how safe is an operation and is it worth taking the risks as compared to what I have at the moment and that's a very individual process pain affects different people differently but just to tease out whether or not it's a suitable time to have a shoulder placement you know something that certainly a specialist can help you with and the way to do that is to start the ball rolling with your GP and having those initial discussions and if if there's already established arthritis I don't think there's going to be too much in the way of boundaries being put up to go and see a sub-specialist to discuss it further.

Phil Orrell

Okay, thank you. This next attendee asks how can calcification of the humerus joint be cured?

Mr Daniel Neen

Okay right so calcification the typical thing that we get to see something called calcific tendonitis now calcific tendonitis is a very painful condition potentially it can send people to accidents in emergency with acute pain in the shoulder it can mimic an infection because the joint itself can become hot and swollen and I said the pain just doesn't solve itself with simple painkillers there are some people out there that have calcium within the tendons that have no symptoms whatsoever and then there are others that are obviously going through absolute hell and there's no rhyme nor reason what we do know is that the most painful stage of a calcific tendonitis is when the calcium is actually being resolved into the body because it goes through these different stages with it being formed and then being there and then eventually being resolved back into the body body basically melts it away so that latter one is usually the most painful sometimes these little lumps of calcium do not disappear though and there are various ways that we can try and help the matter if simple analgesia and time and physiotherapy hasn't helped to a degree again an anti-inflammatory injection over the area so you sort of bathe that inflamed tendon with this steroid anti-inflammatory and that calms it all down it doesn't necessarily get rid of a calcium but can break that cycle and then if that doesn't work then there are two other non-operative interventions that we can try and use one is shock wave where they use an ultrasound probe ultrasound being the same thing that the pregnant ladies have to look at their unborn babies but they have it at a different frequency and what that does is it basically is aimed to try and almost shatter that lump of cows in the heart of stone into pieces alternatively a more direct way of trying to deal with it is something called needle barberage which is in essence and all sound guided needle into that lump of calcium to try and tease it out of the tendon or at least break it up and at the same time as doing that they can also do that anti-inflammatory injection and then finally if that hasn't worked at all there is an operation and the operation is basically to go in keyhole surgery and find that lump of calcium and burn it out remove it.

Phil Orrell

Okay, thank you. I think we have time for one more question this is from a gentleman called Ron who asks I have pain in my right hand side in addition I now have pain in my hip I did have a very bad fall around an eight foot drop onto my right hand side my doctor feels the problem is arthritis in my neck but the hip is inflamed the four was in mid-2017 the shoulder pain has been with me for around a year I’m an active 74 year old do you agree that neck arthritis is the only problem?

Mr Daniel Neen

So how can neck arthritis cause shoulder pain well the reason is that as we alluded to there are seven bones in your neck and at every level there will be a pair of nerves that come out to go on down your arms and they supply set patches of skin with sensation and they also supply a set pattern of muscles and so if there is one nerve that's been pinched in your neck through arthritis potentially with the the little holes that these nerves come out of being narrowed the nerve can become irritated and although the problem is up in your neck the actual pain that you will experience will be further down the arm we call it brachialgia and in essence if it is the fifth nerve down on that side it'll be that patchy which equates to your shoulder so this is one of the things that you have to tease out of the the history examination is it a direct issue with the shoulder or is it a neck referred pain usually if it's tender in that area around there or movements of the shoulder directly cause an increase in pain it'll be something local to the shoulder rather than the neck in terms of your hip the the same principles can occur so you can get a referred pain from nerves being irritated but those nerves are further down your back and they're coming from the lumbar spine which is the small of your back and so the two are very different areas.

Phil Orrell

Okay, thank you. unfortunately time is against us so if we didn't answer your question I can only apologize but if you've provided your name we will answer your questions via email if you would like to discuss or book a consultation our private patients team is available between eight and eight a.m. and 6pm Monday to Friday we're actually offering a discount to all attendees of this session for seven days with the terms listed there on the screen in front of you you will receive a short survey by email after this and I would be very grateful if you could spare a few minutes to let us have your feedback on this session our next our forthcoming webinars will include topics such as foot conditions and hip and knee surgery so you can visit our website to sign up for those and also on our website we've recently launched a sports injury hub which may be of interest to some of you given the topic of this session so there's lots of useful information on there on symptoms prevention recovery and treatments that we offer for various sport related conditions so all that remains for me to say is on behalf of Mr Neen and our team here at Benenden Hospital I’d like to say thank you very much for joining us today and we hope to hear from you very soon. Thank you and goodbye.

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