Orthopaedic Evaluation of Shoulder Pain

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today we’ll be talking remotely once again with Dr. William Seeds. Dr. Seeds is an orthopaedic surgeon who practices orthopaedic surgery in Ashtabula, Ohio. Thanks for joining us today, Bill.

Dr. Seeds: Thank you for having me, Randy.

Dr. Sechrest: Well, Dr. Seeds, what I thought we would discuss today is your approach to a very common problem and that’s the patient that presents to your office with shoulder pain. I think this is one of the most common reasons for a patient to actually go see an orthopaedic surgeon because shoulder pain is extremely common, and as we age we’re going to develop, most of us are going to develop, problems with shoulder pain at some point in our lives. So what I thought we would do today is go through how an orthopaedic surgeon, such as yourself, approaches a patient who comes into the office with shoulder pain. First, what I would like to do, is understand a little bit about what you’re looking for. What types of disease processes might bring a patient into your office for shoulder pain? Second, I would like to understand a little bit about how you go through the process of making that diagnosis and defining what’s causing the patient’s shoulder pain and how you’re going to move on to treatment? Finally, what I would like to discuss are ways in which a patient may be able to provide you with the information necessary to help you make a diagnosis and help with treatment in that patient’s shoulder pain problem? So, anyway, begin by talking a little bit about how you, as an orthopaedic surgeon, view a patient who presents with shoulder pain. What’s sort of diagnoses and what sort of conditions are you worried about when that patient shows up in your office?

Dr. Seeds: Well, Randy, most of the shoulder problems that we see are going to be focused around rotator cuff injuries; possibly labral injuries, as we refer to as slap injuries; impingement problems that people may refer to as bursitis of the shoulder; AC. joint problems, the acromioclavicular joint can also give problems to the shoulder consistent with an arthritic process or an impingement process or an impingement process in the shoulder; instability problems we look for that have to do with the dynamics of the shoulder. We’ll also look at, we’ll be concerned about scapular problems that are associated with the shoulder and how the scapula moves in relation to the shoulder. We’ll also be looking at outlayers such as neck pain that can sometimes produce some of the shoulder pain that we may see. As an aside, we even may go one further step with, depending on the age of the patient, sometimes even orthopaedists we will pick up people with some silent heart disease or something that can show up as shoulder pain where, in part of the workup, we may follow-up with EKG and other things like that to verify that there may be something else going on such as heart problems. So we have to kind of keep a wide range of thoughts when we see this patient and I think the first thing we do, when the patients come in the office, is we’re really under that observation mode. We’re looking at how that patient is entering the office. Are they listing? Are they holding the shoulder? Are they using that shoulder? Are they protracted with the shoulder? Is their neck angulated one way or the other? What’s their posturing? All of those things are signals right off the bat that can start sending the picture to the orthopaedist to start to get an idea of maybe what they’re going to be working against.

Dr. Sechrest: Well, I think that’s a broad range and I think you’ve done a very good job of setting the discussion topic for today and that is that shoulder pain – you know, patients present – they just know their shoulder hurts. They’ve heard all sorts of things. They’ve heard about bursitis. They may have heard about a dislocated shoulder. They may have heard about rotator cuff tears. But they always come with some of a preconceived notion of what’s going on with their shoulder. I think what you’ve pointed out is that the shoulder can hurt for lots of different reasons and it’s our job, as orthopaedists, to really zero in and try to find out what is exactly causing the pain. What condition is causing the pain? What type of an injury may have led to the problem. Or what sort of other medical conditions may be giving you the pain which is actually being perceived in the shoulder, and you and I would call ‘referred pain’. For example, the left shoulder and left arm hurting from a heart attack or sometimes even gallbladder disease can give you right shoulder pain. So it’s not always in the shoulder, and I think that’s a very important point to point out to patients who are starting to experience these symptoms and not really understanding what’s going on with their body sometimes. One of the things I think we ought to distinguish for patients, I think a lot of patients tend to think that when something starts hurting in terms of musculoskeletal system, their orthopaedic complaint, it’s got to be that way for some type of an injury, and a lot of patients tend to come in and may have had a trivial injury that they suggest, or at least they think, that maybe that injury actually led to the problems and the symptoms that they’re experiencing. I think you and I, as orthopaedists, understand that a lot of the conditions that we see, especially in the shoulder, are degenerative conditions; conditions that really aren’t related to an injury – even an injury in the remote past. They’re just problems that have come about through wear and tear over a period of time from what we would term as a degenerative process. Can you give us a little bit of insight about how a patient should go about trying to interpret their history, their history of injury? Something that may have occurred to their shoulder versus shoulder pain that’s just arisen and how you, as an orthopaedic surgeon, try to distinguish those things?

Dr. Seeds: Sure, Randy. I think you’ve brought up some good points in how we do look at the shoulder and how sometimes these presentations are something that may have been in the shoulder for a period of time, and just because maybe something has just happened, they may relate that specific event to that shoulder becoming problematic. I would say that we certainly see a population of patients that do present just like that where they’ve had some degenerative types of problems over many years that we know take a long time to develop, and just recently they had some event that brought them to the office and they’re convinced that that’s probably what did it, but in actuality they’ve had a problem for a long time. I would say that those people are just getting by. They’re able to function. The mechanics are working well enough that they can function and then it just takes that one, if you want to call it a tipping point, where a little event may set everything off into action and that’s how we end up seeing some of these people. So in going back to discussing how these people present with symptoms and how they relate to their problems, the most important thing is to find out exactly why they’ve presented. A lot of times people will tell you they’ve been sleeping on their shoulder wrong or they woke up one morning and they started having shoulder pain or they may have fallen asleep in their car or fallen asleep studying, laying on a desk, or certain activities that sometimes we have a little bit of difficulty figuring out, well okay. How did that event really lead to this shoulder pain or has there been more going on over time? So certainly the traumatic type of injuries where there has been an impaction type of injury, a traction-distraction type of injury from a high speed, like a skiing accident or water-skiing, things like this where there’s some kind of impact or distraction. Those are things that we can more easily relate specifically as a trauma to the shoulder. So we’re looking into that kind of a mindset as to is there something traumatic versus do we believe that maybe, yeah, they might have done some extra work that day but we really can’t discern something that’s specific that really set that problem off. Does that kind of go along with what you’re thinking?

Dr. Sechrest: Yeah, it does. I think that it clarifies several things. What I’d be interested in is really looking at some of the specific things in the history that you want to get at with the patient - when you begin questioning the patient about the nature of their pain and, I guess, how it’s affecting they’re day-to-day life and the types of symptoms they’re having. What’s important to you? What are the key questions you’re going to ask that patient?

Dr. Seeds: Well, certainly, the pain factor is the starting point as to how does this relate to their daily activities? Is this something that does it bother them more at night? Is it something that bothers them after an activity? Does it bother them during the use of the shoulder? Those are important aspects to figure out if that pain is involved in the activity of the shoulder or is it something later after that activity? Or is it, as I said, is it night pain? Is it pain in the morning when they wake up? Is it more of a stiffness and what kind of pain is that? Is it a sharp pain? Is it a throbbing pain? Is it a catching type of pain? Is it a pain that radiates down the extremity or down through the back of the shoulder or up to the neck? All of those things can help us isolate what we may feel is the etiology of that pain or help get a better picture for where the questions may continue to go to isolate that process.

Dr. Sechrest: Now, a couple of things that we need to clarify and, that is, when you talk about radiating pain, can you define that a little bit better? What are we talking about and what is going on in your mind as an orthopaedic surgeon when you see pain that radiates away from the shoulder?

Dr. Seeds: Well, I would relate that to, specifically, I’m looking at two different processes, possibly a third, as to how they describe where the pain may start and where it ends up. Now it may be perceived as I see it as radiating pain, but the patient doesn’t. For instance, they may be complaining of shoulder pain, but they complain down lower below their shoulder. But I’m looking at it as radiating from possibly a rotator cuff problem where I typically see descriptions of pain that are below the shoulder, they’re not actually in the shoulder joint, but they’re referred down to where the deltoid muscles and so forth may be working harder to function for the shoulder and possibly involved in that pain syndrome; or the fact that the rotator cuff is referring pain to an area that may be not specifically over the top of the shoulder. So I’m looking at that as referred pain. The patient is referring to it, “That’s where my pain is.” Then we can look at, as to radiating pain, where the patient may say, “The pain starts here, doctor, and then it goes down my arm.” They can feel it going down their arm and that’s where we start looking more at possibly impingement type of syndromes within the neck where there may be nerve involvement or I have seen shoulder problems, where there is perceived radiation down the arm, where it’s a combined tear and instability problem. That has to do more with inflammation of the shoulder and how close the brachial plexus, the nerves, are to the shoulders. So there can be a lot of these things working together and it’s just important to, like you said, to figure out what that process is and how it’s contributing to the problem.

Dr. Sechrest: Now you also mentioned that patients will sometimes complain of a catching sensation or a shifting in the shoulder. Can you discuss that in a little bit more detail and tell me what you’re looking for when the patient begins to complain of a ‘catching’ sensation. What are we talking about?

Dr. Seeds: Well, I think we all see patients that will come in and describe, that can describe, that possibility where they feel a ‘catching’ sensation with the way they move their shoulder or some of them may refer to it as ‘snapping’ process or a ‘locking’ process. I think it is important for us to figure out if there is pain associated with that snapping? If there is not pain associated with it I still continue to try to work through following up that part of the examination, but I don’t pay as much attention to it if there isn’t pain associated with it or if there isn’t a true instability process with it. I think you’ve got to be able to get through that verbiage of what the patient’s using to describe, “Hey, doc. I’ve got this clunking sound or clicking sound.” Because those are the things where we may look at, say, the biceps tendon and how the biceps is working within the groove where the biceps can flip in and out of that groove sometimes to create that snapping. Or sometimes a thickened bursa in the shoulder can cause some of that snapping. It just depends on how we look at that and what they’ve described, is associated with that, and the use of the shoulder when they’re describing that clunking, catching, or audible pop of the shoulder. Sometimes that popping mechanism may be related to instability. So you’ve got to be able to correlate those things and I think it’s really important to be able to hone in on their verbiage that they are using and make sure what they’re saying is what you’re thinking.

Dr. Sechrest: Now, let’s move on and talk some about when you begin to examine the patient. What are the key physical findings that you’re looking for in a patient to try to help you make a diagnosis of what’s causing their shoulder pain?

Dr. Seeds: What I usually start with is I’ll start with the inspection – observation and inspection. I’ll already be looking at how that patient might have walked into the office, walked into the room, or how they’re sitting and observe if they’re listing like I said or they’re holding the shoulder. What are they doing right there with my interaction is to how they’re reacting to the pain in the shoulder, let’s say, through that examination. I’m going to look at specific things. If, for instance, it’s a female. I’m going to look at how her bra, is she wearing a bra strap? Is it over her shoulder? Is that bra strap painful? Did she come in with a purse on that side of her shoulder? Those are little helpful hints that can help me right away to tell if there’s any involvement in, say, the acromioclavicular joint. Things like that that can be sensitive to problems with bras, etc. But keeping those things in mind, so we’re talking about observation, I’m going to be looking also the mechanics of the scapula that work with that and the neck. So my next step will be the inspection of the shoulder and specific things I’m looking for. I’m going to look at what we call the, basically as I’ve observed the joint – am I looking for swelling? Do I see any redness? Do I see any black and blue, what we may call ecchymosis that could be related to trauma. So I look for that type of aspect. Is there any abnormality of this shoulder versus the other shoulder? Do I see something obvious right off the bat?

Dr. Sechrest: Dr. Seeds, I suspect that, like me, you’re very interested in the range-of-motion and evaluating the range-of-motion on the shoulder. The shoulder has such a very large range-of-motion for probably the greatest range-of-motion of any joint in the body, and we can tell so many things from looking at the range and how pain occurs during certain phases of movement, certain areas of the range-of-motion. How do you go about assessing that in a patient in your office?

Dr. Seeds: Yes. I think that range-of-motion definitely is one of the first indicators that we can use in our examination to start to tip us off to the pain type of symptoms or syndromes that may be occurring in the shoulder. I typically will be looking at the passive range-of-motion. Basically looking at where is the pain related to that motion when I’m doing the passive type of movement for that patient where they’re not actively doing it, but I’m moving their shoulder. For instance, if I do something to move the shoulder into a little bit of external rotation, let’s say, where I keep the arm in and I move the arm out, the hand out. Am I getting any limitations and is there pain with those limitations? Then I start thinking more of a contracture type of problem or an adhesive capsulitis thing where we’re lowing rotation. If they have good passive motion and they’re pain at the end range, let’s say, of elevation. I may be looking more at an impingement type of problem in the shoulder. Is there pain with active motion? When the patients are actively trying to lift their shoulder or lift against resistance so that they’re using muscle now with that range-of-motion. Is there an association with, say, a rotator cuff tear or a labral problem? So, yes, the motion and where that motion is related to the pain is critical to trying to figure what’s going on with that patient’s shoulder.

Dr. Sechrest: Now, nearly every part of the body we, as orthopaedists, have special tests that we use to try to determine maybe something specific. There are some tests that we do that, if the test is positive; and what I’m talking about a test, I’m talking about something we ask the patient to do, or we put the joint through a range-of-motion and we’re looking for very specific things. Are there any specific tests that you do in the shoulder that you feel are very, very beneficial to you in terms of making a very accurate diagnosis?

Dr. Seeds: Yes, I feel there are a couple of things on examination that may help me make a more accurate diagnosis. Number one is just perceived weakness. Does the patient have true muscle weakness with lifting the shoulder and where is that weakness? Does it start off with elevation with a lower aspect versus a higher aspect of where the shoulder is? That helps me determine right off the bat if there’s the possibility of a rotator cuff injury and certain exams that we can do – if you keep the arms in a scapular plane at about 30 degrees where we might have them try to push against resistance – where we’re trying to isolate that supraspinatus tendon, part of the rotator cuff, where we see more rotator cuff tears. Is that an area where we have perceived weakness? I may then go to an examination of looking at what I described as impingement. Do I get an end-range when I try to keep the scapula in place and I lift that shoulder up, am I able to impinge the shoulder and specifically repeat that pain and where does the patient feel that pain in the shoulder? There are certain exams, apprehensive-type of testing, I can do looking at stability of the shoulder where I can do, with the patient lying down, sometimes with patient sitting up, I can do things to rotate the shoulder and try to shift that joint to see if I can recreate any of those instability symptoms the patient may be describing. I do think that what I talked about before, about range-of-motion, passively if there is a loss of essentially internal rotation right away that really does tip me off to a contracture type of problem. I’ll look for crossover type of things where I may be compressing the acromioclavicular joint versus let’s say they have no pain over the acromioclavicular joint but they have pain as I bring the arm over and compressing, I’m trying to look at the labrum inside the shoulder. Certain tests that I’m doing to look at that type of problem as far as a tear; and then I’ll also try to isolate certain activities with the shoulder that relate to the biceps tendon. I think we have some very good tests that can help us figure that process out right away also with just working with resistance and working in different levels of where the shoulder could be on that examination. So I think there are some very good specific tests that we do that really do help us in isolating the problem.

Dr. Sechrest: I think we ought to point out to patients when we do these tests, what we’re really trying to put the shoulder in some sort of a position or have the shoulder work in such a way so that it isolates one specific part of the anatomy; and if that causes pain or causes a sensation that the patient is complaining about we feel that we further isolated the part of the anatomy or the part of the shoulder that’s actually causing the problem. So these tests are very useful from that aspect. But I think all of us are going to, at some point, even during that first visit with the patient, begin to think about what type of imaging we’re going to do with the shoulder because I don’t think many patients are going to get out of the orthopaedist’s office with a shoulder problem and not have some type of imaging done whether it’s plain x-rays or whether it’s some type of CAT scan or MRI scan. How do you approach imaging of the shoulder? When do you talk with the patient about either x-rays or moving on to more advanced imaging?

Dr. Seeds: Well, with my patients, with anybody complaining of any shoulder pain they’re always going to have an x-ray that’s going to be done before my examination. I’m going to have that x-ray present when I do my examination because I believe that all of your shoulder exams and, basically, I do the same thing with the knee and ankle and any joint I’m examining. I have an x-ray that I can correlate directly with my examination so I can specifically look at the relationship of, let’s say, the A.C joint – the acromioclavicular joint, the shoulder itself – the glenohumeral joint, and I’ll look at that to see if I see any early signs of arthritis that could involve the shoulder itself, or the acromioclavicular joint, or calcifications that can be present in the rotator cuff, or other mechanics of that shoulder, that I may be able to see – a sloping acromion – which could be impinging on the shoulder itself, on the rotator cuff. So I’ll look for those things right off the bat and try to correlate that to my examination. As far as progressing on to other studies, again, it depends on the presentation and the history that the patient may have given that needs further evaluation. For instance, if I have a high suspicion that there is a rotator cuff injury or let’s say the patient is very limited with their activity level, the pain level’s high, and I’m suspecting some type of injury like a rotator cuff or labral injury, I will go right to an MRI evaluation immediately to help me and assist me in giving me more information before I start any type of therapy program or advise on any other intervention or discuss the next process that may be involved with, anything from injection to surgery. So, yes, I do use all of these tests and they’re very valuable in going through the examination.

Dr. Sechrest: Now you mentioned injections, and I think most folks, most patients, would think of an injection as something that is done primarily to treat the problem. But I think you and I, as orthopaedists, use differential injections or use what we would consider a therapeutic trial of an injection to try to get at, again, what’s causing the pain. How do you use injections in your practice when you’re trying to evaluate a patient’s shoulder pain? When would you begin to discuss this with a patient?

Dr. Seeds: Yes, I do believe injections can be very valuable in helping differentiate some of the pain complaints and, again, it just depends on how that patient presents and what I’m trying to figure out as far as where the etiology of that pain, where’s the origin, of it. Is it specifically related to the acromioclavicular joint itself? Is it related to impingement or subacromial symptoms? Or is it intraarticular within the joint itself of the shoulder? So sometimes I may discuss with patient that I’d like to inject their shoulder as a diagnostic injection to help me see if I can isolate where that pain may be because some people can have symptoms related to the acromioclavicular joint and have no real impingement but just pure joint pain. Other people can have symptoms that, let’s say they have a labral injury that’s inside the shoulder itself but they’re also giving you symptoms of impingement, which sometimes they are combined, but you might want to diagnostically be able to figure out is it inside the shoulder or is it subacromial, so you’ll do a subacromial injection and you may get relief immediately and know, okay, that’s my problem. It isn’t inside the shoulder, it’s above the shoulder. So those things can be very valuable for you and sometimes therapeutic. Depending on the examination and you’re confidence level that the integrity of the soft tissue and rotator cuff, sometimes you can go ahead and use that also as a treatment plan as long as you feel comfortable that the soft tissues, as far as the rotator cuff and other structures, are in good working order and intact and you’re just purely dealing with some inflammatory process.

Dr. Sechrest: I think we ought to point out to patients that when we do these injections we normally inject two different types of medications and they’re usually mixed together. So we’ll mix a little bit of an anesthetic such as Novocain, Lidocaine, or Bupivocain – we’ll mix that with a little bit of cortisone – and what gives you that immediate pain relief is the Novocain or the Lidocaine that’s used. For example, you mentioned the acromioclavicular joint. When we’re trying to decide whether the pain is coming from the acromioclavicular joint or the subacromial bursa, we may just simply put Novocain, maybe with a little bit of cortisone, right into the acromioclavicular joint. Now we know that that medication stays within the acromioclavicular joint. It numbs up everything around the acromioclavicular joint in the capsule and the bone ends that may be causing the pain, and if 100% of the pain goes away, then we tend to interpret that as all the pain is coming from the acromioclavicular joint. And conversely, like you said, we can put it in different places and try to say, okay, all of the pain is coming from the subacromial bursa. There’s no pain relief when I inject into the joint. There may be no pain relief when I inject into the acromioclavicular joint. But when I inject into the subacromial bursa, all of the sudden all the pain’s gone, we know that the problem most likely is originating in that compartment of the joint. I think the therapeutic part of the injection comes from that addition of the cortisone. The cortisone is a very potent anti-inflammatory medication and over a period of several days it begins to reduce the inflammation, reduce the pain in the shoulder joint, and that may last for several weeks. Sometimes it may be enough to knock the problem out and the problem not return on an indefinite basis. But I think patients are sometimes confused by what medications we’re using and what those medications are doing, and what type of information they’re getting, and then all of them are interested in how is this going to help me resolve the problem. How is this going to actually be therapeutic? So I think that’s useful information for patients and I always try to explain when we go through these injections as part of our diagnosis. Do you have any other observations on what I’ve just said?

Dr. Seeds: Well, I agree completely with that. I think it’s just important that we explain why we’re using it and what we’re trying to, what’s the end result we’re trying to obtain from the use of the injection in helping us figure out what the problem is.

Dr. Sechrest: I think this has been an excellent discussion about how we, as orthopaedists, approach a patient who comes in with shoulder pain, and I think you and I both, at this point in time after we’ve gone through the history, we’ve understood what the patient is complaining about, we’ve gone through an examination to where we have a pretty good feel for how that shoulder is functioning, and then we’ve looked as some x-rays and perhaps we’ve done some imaging studies that are more advanced than plain x-rays. We may have done an MRI scan which is by far the most common test that you and I are going to use today to try to delineate what going on with the shoulder. I think we probably ought to cover one other aspect of more advanced imaging and that’s the use of an MRI scan arthrogram or a shoulder arthrogram. Do you find the addition of actually adding dye to the shoulder still is of benefit in terms of trying to get a more definitive diagnosis? Do you use that commonly?

Dr. Seeds: I can tell you that, yes, I used to use the dye intraarticular injections combined with the MRI and I have found that it really was an inconsistent test for me as far as who was reading the test. Did it show some of the labral tears? Yes, it did. Were my exams getting better in combination with the MRIs where I was able to feel that I was able to feel that I was able to pick it up even though the MRI may not have shown it? I believe that’s true also. I have gotten away from doing the injections, the arthrograms, with MRI. I felt that, at least for me, I get enough information from the MRI and I feel that it’s enough at this point for me, along with my examination, to figure what our next steps are going to be.

Dr. Sechrest: I think that for a lot of these patients the next step may be doing an arthroscopy or doing what we would consider a diagnostic arthroscopy. How often do you find yourself moving towards arthroscopy today, with all the imaging techniques that we have and the pretty refined sense of diagnostic skills that orthopaedists have to try to really define the problem before they consider some sort of an invasive surgical procedure? How often do you find that you suggest to a patient, “I’m not quite certain what’s going on with your shoulder. This is what I think is going on and we’re going to actually put a TV camera in your shoulder and have a look around.”

Dr. Seeds: That’s a good question, Randy. I feel my examination skills have gotten, are pretty high tuned, in combination with my x-ray and my MRI, where I pretty much feel that I have a good understanding of what they’re presenting symptom is and what I’m going to treat. I would say I do occasionally do what you’re referring as a diagnostic arthroscopy where I may not be sure why that patient is having impingement symptoms. Is there a labral pathology that I’m not picking up on examination? There are times, especially with work injuries, that I’m required to do a diagnostic arthroscopy before I can even treat the patient. But I would tell you that I feel very comfortable with my examination and that most of the time I’ll give that patient, what I’ll tell them is, “Look. This is my plan. This is what we’re going to start with.” and taking care of, because a lot of patients will show those impingement symptoms so you’re initially going to be treating that impingement when you go in the shoulder. You’re going to be doing a decompression. You’re going to be looking at the shoulder and the labrum and so forth while you’re there. So I let patients know of the possibilities that, “Hey, even though I’m treating this impingement there may be something that the scan hasn’t picked up and my examination has not shown me where I may need to take one more step and go ahead and treat that labrum or there may be some partial tearing in the biceps in the shoulder that I didn’t expect.” But what I look to assure them of is that everything will be completed at the time of my treatment but it’s really more informing them of those possibilities, I think, that you may be referring to as ‘diagnostic examination’. Maybe I’ve gotten away from saying, “Hey, this is going to be a diagnostic examination where I am treating the impingement. We are going forward with this process and there may be more associated with it.”

Dr. Sechrest: So if I understand you correctly, what you’re saying is that you very rarely do a pure diagnostic arthroscopy of the shoulder anymore. You have a pretty good idea that when you suggest arthroscopy to a patient you’re going in, not only to have a look around to confirm the diagnosis, but you’re going to move towards fixing the problem at that time, and you’re pretty certain, at that point, what you’re going to be doing in the shoulder and pretty certain of what you’re going to find. Is that accurate?

Dr. Seeds: Yes, I would say absolutely.

Dr. Sechrest: Well, I think that’s good information. I do think that’s been somewhat of a shift and a lot of it had to do with the MRI scan. The MRI scan has given us far more information than we had 30 years ago in terms of shoulder anatomy or any joint anatomy and it has allowed us to really refine our diagnosis to the point that we don’t necessarily have to look in the shoulder to see what’s going on. 30 years ago, well, let’s say 20 years ago, it was not uncommon to actually use the arthroscope to actually get into the shoulder without making big incisions so that we could actually make a diagnosis and see what’s going on. Clearly we could fix the problem at point in time, but it was not uncommon to have a patient be told, “We’re just going to go take a look around. We’re not going to fix anything. We’re going to stop. We’re going to come back. We’re going to talk to you about what we find and then we’re going to go back and do whatever surgery is necessary”, and that may have been an open procedure. It may not have been an arthroscopic procedure and may have required a bigger incision. So that’s been a huge change over the last, I would say, 15 years to 20 years. As we close this discussion, which I think has been an excellent discussion in terms of preparing patients for what they should expect when they go see an orthopaedist. They’ve been referred to an orthopaedist for shoulder pain. They really don’t know what to expect. This has been an excellent discussion to prepare them for what’s going to happen in the office and, perhaps, what’s going to happen to them over the next several weeks as you and I, as orthopaedists, try to define what’s going on with the shoulder, try to treat that problem, and try to decide how we’re going to get them in the best functional state that we can. Is there anything that you would suggest that patients need to do in terms of helping us, as orthopaedists, get to the bottom of our shoulder problem? What are some key things? Either questions patients should ask or information they should be prepared to give their surgeon on that first visit that may help that surgeon really get to the bottom of their problem?

Dr. Seeds: Well, I think we’ve summarized basically everything that we go through and what we’re looking for as far as trying to come up with a complete diagnosis of what’s going on with that shoulder. I think the best thing the patients can do is really take those surveys or things that we do initially, or the nurses may do to hone in on the type of pain that they’re having. Is it sharp? Is it throbbing? When is that pain? Is it related to what activities? Those things are very important because they do all make a difference in how we look at it, and being able to be specific about where the pain is and when it started for them. All of those issues are very important and I think that sometimes that the patients don’t understand that we listen, those verbal cues are very significant and important when we’re going through that history with the patient. You know as well as I do and our peers, that when a patient gives us a real accurate and a good history we can sometimes, we may have 90% of the picture right there before we even examine the patient. So for the shoulder, I would say that a lot of those issues are very important and also making sure that we’re just as interested in their other comorbidities, other problems. Are they diabetic? Do they have other systemic problems? Things like that that may play into these shoulder issues.

Dr. Sechrest: I think that’s excellent advice. I do think, we’re always told as medical students, that 85% of the diagnosis comes from the history and the other 15% comes from just confirming what our initial, sort of, decisions are made on patterns and it’s very important the first information that you give the orthopaedic surgeon is as complete as possible because we, as orthopaedic surgeons, tend to, sort of, decide what’s a possibility and how we’re going to approach that problem right off the bat and that information that we get right up front is very important. It may seem like just one more piece of paperwork to fill out if you come to the office and the surgeon who is working there is asking you questions that you just don’t want to take the time to fill out. But it’s so important. It’s so important to be accurate and think about that beforehand so that the surgeon goes in the right direction from the start. So thank you very much for explaining that. Thanks again for joining us today. Are there are any last minute comments you’d like to make on today’s topic as we close?

Dr. Seeds: Yes, Randy. One last comment I’d like to say, which you just brought up, that is, I think, real important. I always get a couple of patients and it could be a couple of patients every office day who will say, “Boy, doc. I didn’t know you actually read all that stuff I wrote down. I thought it was just nebulous paperwork. I didn’t really think people looked at.” So I really think that’s great that we’ve impressed upon that they’re just helping us hone in on these things and we look at everything. All that information they’re putting on paper – we’re looking at it.

Dr. Sechrest: Yes, I agree. I think people think sometimes we just get the MRI scan and there’s the diagnosis. But it’s that not that simple at all. It’s very important what patients tell us. So thanks for validating that and thanks again for joining us today. I look forward to further discussions in the future. Thank you.

Dr. Seeds: Thank you, Randy.