Physiotherapy

Physiotherapy is crucial for management of shoulder pain or instability. Often pain or instability around the shoulder is a result of imbalance of the muscles that control the shoulder blade as well as the rotator cuff. Physiotherapists are experts at assessing and treating these imbalances. Once a program is learned often it can be continued at home as part of your regular fitness regime 3-5 times per week.

Activity Modification

There are conditions of the shoulder that require a temporary or sometimes permanent modification to your activities. For example, if you have shoulder pain due to impingement or a small rotator cuff tear that is amenable to non-operative care, avoidance of aggravating activities during therapy such as weight lifting or repetitive overhead activities may be necessary to change your shoulder symptoms.

Medication

Over the counter pain medications can help a great deal with joint pain. Traditionally, Tylenol (acetominophen) has been used as a first line treatment for arthritis pain, for example. However, recently there has been some question as to the value of Tylenol for arthritis pain and back pain. Some well-designed placebo controlled studies have shown minimal benefit of Tylenol when compared to placebo for arthritis pain.

Anti-inflammatory medications (NSAIDs) such as Advil (ibuprofen) are very useful to control both inflammation and pain. There are a number of products on the market, over the counter and prescription that can be suggested by your surgeon or family physician. One over the counter medication that lasts longer than Advil and you may find useful is Aleve (naproxen). There are also prescription strength anti-inflammatory medications that you may want to discuss with your surgeon or family physician such as toradol, Vimovo or Celebrex, for example. Topical anti-inflammatory creams are available that can allow for treatment of the pain/inflammation with less risk of systemic side effects.

There are some side effects to any medication but in particular with anti-inflammatories you should speak with your family physician if you have a history of ulcer, heart disease, high blood pressure or kidney problems, to name a few. Depending on your condition you may only need medication for a short course. For example, an acutely painful shoulder without major internal injury may respond to a short course of anti-inflammatories and physiotherapy which limits the potential side effects of long term anti-inflammatory use.

Eventually, if the pain becomes more severe, it cannot be managed with over-the-counter medications or anti-inflammatories. Sometimes, stronger pain medications such as narcotics are required. These medications should be used as a last resort. There are many more side effects, and these medications can be addictive. A consultation with a surgeon is recommended if the pain is severe enough to require narcotic medications.

Glucosamine/chondroitin

These supplements can be purchased in many supermarkets and health food stores. There is no good evidence in well controlled scientific studies of significant pain relief or improvement in function with use of these supplements. At this time there are no high quality scientific studies to demonstrate a significant effect of other natural medications on arthritic pain or function.

Injections

There are different types of injections that can be provided to help manage your symptoms. Depending on the type and severity of your condition, injections can have variable effectiveness. Ask your physician whether you may benefit from different types of injections.

a) Corticosteroids
These “steroid” injections can be very useful to help treat shoulder issues. In the shoulder these injections are often important to help your surgeon diagnose what damaged structures are causing the symptoms. The benefits from a steroid injection in the shoulder can be dramatic. The effect can last for a few weeks to several months but in order to obtain longer term benefit the injection should usually be combined with a home physiotherapy program to strengthen the important stabilizing muscles of the shoulder.

b) Viscosupplementation (Hyaluronic Acid)
These injections are like a lubricant that is put directly into the joint. They contain hyaluronic acid which is a natural substance found in healthy joints. There are many studies showing the benefits of viscosupplementation in degenerative knees. The same principles apply to an arthritic shoulder so health care providers have expanded these injections to other joints such as shoulders.

The cost of these injections are not covered under the medical services plan. Depending on the brand of injection material used, the cost can range from $350-$550. Most extended health care plans will cover the majority of the cost.

c) Platelet Rich Plasma (PRP)
There are many studies documenting the effectiveness of PRP in the treatment of musculoskeletal disorders. The best evidence is for its use is in early arthritis of the knee however the use of PRP is also supported in other joints or for diseases such as tendinitis. The doctor is injecting a high concentration of your own platelets into the area of damage. Platelets are a normal component of blood, and they assist with blood clotting. However, they also contain many growth factors that can help with pain relief in degenerative tissue or painful joints.

The procedure involves the drawing of a blood sample from the patient. The blood is then spun in a device called a centrifuge. This separates the components of the blood. The doctor will then take the platelets from this sample and inject them into the area of concern. Patients cannot take anti-inflammatories when trying this type of treatment for 5 days before or after this injection.
PRP is also not covered under the medical services plan. The costs range from $650-$850. Some extended health care plans will cover the cost of this treatment.

d) Stem Cell Treatment
The use of stem cells to treat joint disease is a relatively newer treatment available to patients. At this time, this is not offered locally. Some patients travel to the US to pursue stem cell treatment. Talk to your doctor to see if you are a candidate. There are no long term studies documenting the benefits of this treatment. Early results seem promising, but more research is needed.

Risks or Complications
Whenever a doctor uses a needle to inject a substance into the body, there are potential risks. There is a risk of infection, but the risks are very small. After any injection, some patients notice an increase in pain and swelling for a very short period of time. This is usually normal. However, if the pain and swelling are quite severe, there are difficulties with bending or using the joint, there is redness, or a fever develops then this is abnormal. This is a sign that an infection is developing and you should go to an emergency department right away.

Some patients develop local reactions to the substance that was injected into the joint. Some patients can experience allergic reactions to various hyaluronic acid injections. These reactions are very rare.