Can I avoid shoulder replacement surgery? The evidence for shoulder replacement alternatives
Ross Hauser, MD, Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
In this article, we will explore options and alternatives to Shoulder Joint Replacement. We will also discuss the various non-surgical regenerative medicine injection techniques.
You wake up in the morning, your shoulder is killing you. No matter which way you turn, your shoulder hurts.
You wake up in the morning, your shoulder is killing you. No matter which way you turn, your shoulder hurts. You hardly slept because of your shoulder. You get up, you stand at the foot of your bed and you begin your morning trying to figure out how far you can lift your arms up. Then you start “loosening up,” and hoping you can get by today without a lot of help from medications. You are also pretty tired.
Hopefully going to the toilet, washing, and getting dressed will not be a big chore and you will not have to bother your spouse or other loved ones to help you do these simple tasks.
For some of you, you have to go to work like this, so you dedicate a portion of your day to figuring out pain management, altering your shoulder movements, and trying to survive.
I am leaning towards the shoulder replacement because I do not know what else to do
We see shoulder pain patients, and no matter how unique their story is, most have the same common problems and the same common medical history. They tell stories like this:
I have had shoulder pain for a long time, my line of work is physically demanding. I have been to my doctors and specialists many times. I have been given varying doses of different pain medications, muscle relaxants, and anti-inflammatories. I have had cortisone twice. I have been sent to physical therapy, tried chiropractic and various electro-stimulation products. I am at the point now that my visits to the orthopedics are long discussions about surgical options.
I am here to explore other options. I do have a good range of motion in my shoulder though I cannot lift my arm over my head because of weakness. I can pick up objects and carry them, I just can’t left them to a table or platform above my waist.
Doctors aren’t helping you despite the medications and cortisone
In the stories we hear we, the long medical history will list treatments options you may have been recommended to for your degenerative shoulder disease. These treatments do help some people. For some, perhaps like yourself, symptom relief was temporary. For others, the pain relief lasted hours or days if at all.
If you are reading this article it is more than likely you are in that group of patients who are still seeking answers despite years of these treatments and even a past history of “shoulder preserving arthroscopic surgery,” which at this point, does not appear to be successful in preserving your shoulder.
At your last follow up visit with your orthopedic surgeon, a long discussion may have taken place over whether to continue with your conservative care options or pursue the shoulder replacement. Your concern with these “conservative care” treatments is that you will continue to have more pain, more grinding, more popping and more clicking. You recognize that you are only being symptom managed and you need to fix it once and for all.
The road to shoulder replacement Conservative Care followed by Arthroscopic shoulder surgery
- You may be on Anti-inflammatory medications. This is not something we recommend. Please see our article When NSAIDs make pain worse.
- Stronger Pain medications. This particular recommendation has very little long-term appeal as it can make your situation worse. Please see our article, when Painkillers make pain worse.
- Corticosteroids / cortisone or steroid injection. This is also a treatment we do not recommend. Please see our article Alternative to cortisone shots
Arthroscopic shoulder surgery
- We frequently see patients who have had surgery for shoulder pain but are subsequently left with more chronic pain after surgery. The surgeries, such as arthroscopic surgery for glenoid labrum tears, Slap lesions of the shoulder, and of course for various degrees of rotator cuff tears and damage will sometimes lead to rapid shoulder deterioration. When these surgeries fail, shoulder replacement will be recommended.
So here you are, years of treatment, maybe a past surgery, you still have pain. Why?
Many times a patient will come into our office with advancing osteoarthritis of the shoulder. When they describe their shoulder pain they say things like:
- “My shoulder is barking at me today,” or
- “My shoulder is letting me know it is there.”
When we manipulate their shoulder to test for range of motion and we all hear the audible pops, clicking, and grinding, sometimes the patient tells us “My shoulder is talking.”
Intuitively these people know that their shoulder is talking to them. Do they understand what their shoulder is saying? Do you?
Your rapidly degenerating shoulder is trying to function and survive. It swells up so it can function as best it can. Swelling holds the shoulder together. Your shoulder is trying to hold itself together.
When your shoulder swells up. It is talking to you. It is saying “I am not stable, I have instability. I am going to swell up to hold myself together.” If you are reading this article, this may be happening to you all the time. Here is the science of what your shoulder is doing. When you understated what your shoulder is doing, you can understand what may be the best treatment for you.
This is research published in the Journal of Shoulder and Elbow Surgery.(1)
Here are the highlights:
- Shoulder osteoarthritis is a gradual wearing of the articular cartilage accompanied by degenerative rotator cuff tears. This pathologic (disease) disorder is related to inflammation, oxidative stress, and angiogenesis.
- What does this mean? What is your shoulder saying?
- Angiogenesis is the formation of new blood vessels. In degenerative shoulder disease, new blood vessels can be beneficial as they bring healing and growth factors to the site of injury or they can be harmful as they open new highways for chronic inflammation (chronic swelling) which eventually erodes joints.
- So your shoulder is telling you that it is creating more blood vessels to bring more inflammation to it.
- Degenerative alterations in the shoulder may prompt production of cytokines and angiogenesis-related proteins, evoking rotator cuff diseases.
- What does this mean? What is your shoulder saying?
- Cytokines are small proteins that cells secrete when they want to communicate with each other. Cytokines, while beneficial in acute injury to help heal damage, become detrimental in chronic pain situations. They sustain chronic inflammation and create more pain. How? We are going to briefly discuss a 2007 paper that researchers have heavily cited for its understanding of Cytokines that appeared in the journal International anesthesiology clinics. Here we will see that your shoulder is no longer talking but yelling at you!
A heightened sense of shoulder pain caused by runaway inflammation. Your brain is getting lots of pain messages.
- In this paper from the University of Cincinnati, (2) doctors say:
- “There is significant evidence showing that certain cytokines/chemokines (part of the cytokines family of inflammation) are involved in not only the initiation but also the persistence of pathologic pain by directly activating nociceptive sensory neurons. (Simply excessive messages sent to nerve cells that something is hurting), but also certain inflammatory cytokines are also involved in nerve-injury/inflammation-induced central sensitization and are related to the development of contralateral hyperalgesia/allodynia. (A heightened sense of pain caused by runaway inflammation).
What all this means is that your shoulder hurts worse than it should because your shoulder is trying to get your attention. What is your shoulder trying to get you to do? It wants you to stop doing what you are doing to make it hurt.
Your shoulder is under stress physical and emotional. Yes, your shoulder gets stressed out.
For someone in chronic pain, if you told them that shoulder is stressed out, burnt out, ready to give up. They will probably not argue with you. Because that is the way they feel some days. Stressed, tired, ready to talk about shoulder replacement. Let’s recap what we discussed to this point:
- Your shoulder is unstable. The ball and shoulder socket are banging against each other because your rotator cuff tendons, muscles, labrum and shoulder ligaments are damaged and not holding your shoulder together.
- Your shoulder is asking your immune/repair system for more inflammation to bring swelling to act as a “cast,” to hold the ball and shoulder socket in proper alignment.
- But the shoulder knows it cannot stay in a constant state of swelling. Chronic inflammation is toxic. It burns out and erodes the joint. Your shoulder is hurting more because it is trying to send you more pain signals that this situation is on the verge of joint “death,” – your shoulder will not survive prolonged chronic inflammation and will need to be replaced.
The shoulder becomes highly inflamed
Back to the research we cited above (1):
- In the two groups of patients examined and divided by less severe and more severe osteoarthritis and rotator cuff tear, measurements of the patients:
- Cytokines (a way to determine the number of pain signals and messages going back and forth in your shoulder between cells),
- growth factors (healing chemicals that your body is sending to the shoulder)
- and angiogenic biomarkers to determine if and how much blood vessel making activity was happening
- Findings: Well known inflammatory factors such as interleukin 8, tumor necrosis factor α, and interleukin 1β was considerably elevated in synovial fluids of the patients.
- (The whole joint was highly inflamed and in a state of erosion).
- The joint inflammation highly enhanced insulin-like growth factor 1 and transforming growth factor β1 (TGF-β1) in the synovial fluids and serum.
- (The inflammation was more destructive, potent and lethal to cells.)
- The toxic situation is shown by upregulated inflammatory factors that have created oxidative stress throughout the shoulder).
Now let’s talk shoulder replacement – Some doctors suggest shoulder replacement surgery is the only answer
You may be wrestling with the idea of shoulder replacement because you are a worker who needs to work. Shoulder replacement brings with it possible hope, but it also brings with it, the risk of surgery, possibility of complications, surgical recovery and rehab time. For some, the problem with the surgery is not the surgery itself, it is the rehabilitation and the down time away from exercise, physical activity and sport involvement. For others it is time away from work. For these workers, some consider shoulder replacement as a means of “forced retirement,” or “disability.” At what price do you have the surgery? At the cost of your job? At the cost of maintaining a fitness lifestyle? Is replacement surgery the only way?
Often we will see a patient who says, “I went to two reputable orthopedists, both said surgery was the only way.” Below we are going to show you research that surgery is not the only way for many people. Surgery is usually the only way when the shoulder bones are fractured or there is gross anatomical failure.
The research: When the shoulder is “too far gone.”
Some doctors suggest shoulder replacement surgery is the only answer: This is from the journal Arthritis Research and Therapy: (3)“While research in cartilage regeneration has not yet been translated clinically, the field of shoulder arthroplasty has advanced to the point that joint replacement is an excellent and viable option.”
Why? Because of poor tendon healing and irreversible changes associated with rotator cuff inflammation.
- In other words, the shoulder is “too far gone.”
- But the same researchers also say: “Future treatment types involving biologics and tissue engineering (stem cells) hold further promise to improve outcomes for patients suffering from shoulder pathologies.”
- Stem cells used during the course of surgery – Many of you reading this article may have already had a consultation for shoulder surgery. The surgeons may have advised you that they were able to bring stem cells into the surgery to facilitate healing. We address this in our article My surgeon wants to use Platelet Rich Plasma and Stem Cell Therapy during surgery.
Some doctors suggest shoulder replacement surgery may make things worse – shoulder replacement recovery time – complications are often lengthy and sometimes never go away.
Researchers from Texas Orthopedic Hospital, the University of Houston, University of Texas, (4) released their findings and documented that the number of shoulder replacements being performed has increased exponentially in recent years, with a corresponding increase in the number of second surgeries to fix the first one.
- In patients surveyed for this study: 21.6% (8/37) required reoperation for postoperative complications.
- Overall, 54% of patients (20/37) suffered from intra- or postoperative complications.
CONCLUSION: Shoulder implant replacement improved function in the present series, but with a high rate of complications and reoperations.
This, of course, will throw a big concern at patients – shoulder replacement recovery time – complications are often lengthy and sometimes never go away.
In this video Danielle R. Steilen-Matias, MMS, PA-C discusses treating nerve pain following shoulder surgery.
It is not uncommon for us to see patients after shoulder surgery who continue to have shoulder instability issues. Other times we will see patients after shoulder surgery who have continued pain. It may be the same pain that they had before surgery or it may be a different type of pain. What we find in many of these people is that even though healing is occurring and the shoulder looks well, the pain they are having is related to the nerves that may have been impacted during the surgery. We treat these patients with Nerve release injection therapy or more commonly hydrodissection.
What is Nerve Release & Regeneration Injection Therapy?
NRRIT is a nerve hydrodissection technique that is highly successful for releasing peripheral nerve entrapments. It is a quick, straightforward process injection procedure often providing instant relief results for the patient! In the procedure, the practitioner uses ultrasound guidance to identify the nerves being entrapped. Next, simple dextrose is injected around the nerve to nourish the nerve and mechanically release it from the surrounding tissue, fascia, or adjacent structures.
Soft tissue damage after shoulder replacement, a leading cause of surgery failure
In September 2019, a paper in the Clinics in orthopedic surgery (5) noted that, “The majority of patients with shoulder instability after anatomic shoulder arthroplasty (replacement) have both soft tissue imbalance and component malposition. Rotator cuff (surgical) repair after shoulder replacement has also had a poor success rate. Additionally, revision surgery with anatomic components and soft tissue reconstruction has had a high failure rate. Consequently, both instability and symptomatic rotator cuff dysfunction after anatomic shoulder arthroplasty are preferably treated with revision to a reverse prosthesis.” In common terms, Reverse shoulder surgery.
Understanding the reverse total shoulder replacement and conventional shoulder replacement surgery.
For these patients, conventional total shoulder replacement may result in pain and limited motion. Therefore a reverse total shoulder replacement may be suggested as an option.
The procedure sounds exactly as it is named. In a traditional shoulder replacement, a plastic “cup” is fitted into the shoulder socket (glenoid), and a metal “ball” is attached to the top of the upper arm bone (humerus). In a reverse total shoulder replacement, the socket and metal ball are switched.
The benefits of the reverse procedure are studied in a paper published in the medical journal Orthopedics.(6)
- The paper suggests that a reverse total shoulder arthroplasty is better suited for older patients with glenohumeral arthritis and a deficient rotator cuff.
- However, as a semiconstrained prosthesis, (that is implants which create artificial stability by limiting the prosthesis range of motion) a conventional reverse total shoulder replacement in a young patient could fail over time because of the polyethylene wear and subsequent osteolysis – the joint replacement causes accelerated bone loss.
Postoperative outcomes are disappointing, and the complication rate is high
- The researchers in the current study suggest at first that a metal-on-metal prosthesis may avoid this type of failure. However, they concluded: “Although metal-on-metal total shoulder replacement may appear to be an attractive choice in the treatment of young patients with limited reconstructive options, postoperative outcomes are disappointing, and the complication rate is high.”
Another study from Dr. Pascal Boileau of the Department of Orthopedic and Sports Surgery Pasteur 2 Hospital, University Institute of Locomotion and Sports in France examined outcomes and complications in young patients undergoing revision reverse total shoulder arthroplasty (RTSA) for failed prior total shoulder arthroplasty or ball replacement and compared them with those of older patients undergoing the same procedure.
- While reverse total shoulder arthroplasty is effective in reducing pain and improving function after failed arthroplasty in young patients, complication rates are high and expectations should be managed appropriately. Subjective outcome scores are worse for older patients.(7)
Shoulder replacement works better for older patients…but complications, painkiller use, and complications are still a concern to surgeons
Here are the bullet points to recent medical studies:
- Doctors in the United Kingdom write in the medical journal Shoulder and Elbow that the management of glenoid bone loss is a major challenge in both complex primary and revision arthroplasty surgery.(8)
- Doctors writing in The Journal of Bone and Joint Surgery noted that shoulder surgery was seen as a further complication of rotator cuff disease. “Secondary rotator cuff dysfunction is a recognized complication following shoulder arthroplasty. We hypothesized that the rate of secondary rotator cuff dysfunction would increase with follow-up and result in less satisfactory clinical and radiographic outcomes.” (9)
Complications leading to re-operation are often multiple and underestimated
Doctors writing in the Muscles, ligaments and tendons journal, suggest that if you had a surgery that failed to fix your shoulder pain – it is not recommended that you get a second surgery to fix the first one because 36% of those surgeries fail too.(10)
- Shoulder replacement infection: In another study, doctors say that one of the greatest risk factors for infection after shoulder replacement were history of a prior failed shoulder surgery. So replacing the shoulder in an attempt to fix the first shoulder surgery had a high risk of infection.
Back to the study from Dr. Boileau: The most common causes of revision surgery after reverse total shoulder arthroplasty (RTSA) are:
- prosthetic instability (38%),
- infection (22%),
- humeral problems (21%) including loosening, unscrewing and fracture,
- and, lastly, problems of polyethylene glenoid loosening (13%).(7)
Doctors at the University of Washington sum up shoulder failure surgery as: “…surgery has failed when it does not achieve the expectations of the patient and the surgeon. Failure can result from stiffness, weakness, instability, pain or failure to heal as well as from complications such as infection or nerve injury
Every surgery has a risk of failure whether it is an operation for dislocation, rotator cuff tear, arthritis or fracture. Because fracture fixation, Bankart repairs, rotator cuff repairs, shoulder joint replacements and reverse total shoulders are performed commonly, a substantial number of patients have experienced these failures.”
Obesity is a complication concern in shoulder replacement
- Doctors at the University of Alabama at Birmingham found that patients suffering from Metabolic syndrome, that is large waistlines (obesity), high triglyceride levels, high cholesterol, high blood pressure, and high cholesterol, are associated with considerable complication risk before, during and after shoulder replacement surgery.(11)
Doctors from the Mayo Clinic writing in the Journal of Bone and Joint Surgery discuss the problems of obesity causes in patients after shoulder replacement surgery.
Here is what they said:
- Increasing Body Mass Index (Obesity) was associated with an increased risk of the need for a second or revision surgical procedure, reoperation, revision for mechanical failure, and superficial infection.
- Increased BMI was also associated with an increased risk of revision for mechanical failure.
- The most marked association between increasing BMI and any complication in shoulder arthroplasty was its association with superficial wound infection.
- It is important to consider these findings when counseling patients, estimating risks, and estimating complication risks in policy decisions.(12)
Alternatives to shoulder replacement surgery
In regenerative injection techniques like Prolotherapy, Platelet Rich Plasma Therapy or Stem Cell Prolotherapy, the goal is always to preserve and regenerate these cushions and connective tissues rather than remove them. It makes our job here at Caring Medical a little more difficult when treating a patient who has had an extensive procedure, but it is still possible to achieve healing after surgery.
The videos above and below show and describe both the Prolotherapy and PRP injection techniques we offer. Below we discuss the science.
Ross Hauser, MD explains and demonstrates a Prolotherapy treatment to the shoulder.
- This particular person is not sedated. The treatment is well tolerated. The treatment begins at 1:36.
- The first injection was intra-articular, directly into the shoulder joint.
- Next the acromioclavicular joint. Shoulder osteoarthritis, rotator cuff tendon issues including tears as well as tendinosis, responds well to Prolotherapy.
- Next are the posterior shoulder structures including the posterior joint capsule as well as the various ligament attachments in the back of the shoulder.
- Next the interior structures in the front of the shoulder are done including the ligaments as well as the various rotator cuff tendon attachments including the Supraspinatus tendon.
- Prolotherapy is effective for rotator cuff tears, labral tears and biceps tendonitis, various tendonitis as well as shoulder instability.
- Finally treating the acromioclavicular joint, or AC joint as the biceps tendon attachments.
Caring Medical Research:
In the same manner, we present research on shoulder replacement surgery, we would like to present information on regenerative medicine injections. Our focus is on simple dextrose Prolotherapy as the first course of action. In more problematic cases, we may rely on Platelet-rich Plasma injections or bone marrow concentrate commonly referred to as stem cell therapy.
Dextrose Prolotherapy, as described in the video above is a series of injections that stimulate inflammatory healing that reboots the shoulder’s repair process.
First we will look at the learning points of Caring Medical research.
A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois
Hauser RA, Hauser MA. A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;1(4):205-216. The article in its entirety can be downloaded as a PDF
94 Patients treated with Prolotherapy with the hopes of avoiding surgery
Here is the summary of our research:
- We studied a sample of 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy.
- An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment.
- The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation), with Prolotherapy, including the 39% of patients who were told by their medical doctors that there were no other treatment options for their pain and the twenty-one percent who were told that surgery was their only option.
- Over 82% of all patients experienced improvements in sleep, exercise ability, anxiety, depression, and overall disability with Prolotherapy. Ninety-seven percent of patients received pain relief with Prolotherapy.
Conclusion: In this study, patients with chronic shoulder pain reported significant improvements in many clinically relevant parameters and overall quality of life after receiving Hackett-Hemwall dextrose Prolotherapy.
In our research, published in Clinical medicine insights. Arthritis and Musculoskeletal Disorders, (13) Ross Hauser, MD and Danielle R. Steilen-Matias, MMS, PA-C contributed to findings suggesting Dextrose Prolotherapy has been able to reduce pain and disability of traumatic and nontraumatic rotator cuff conditions.
- Research revealed that treatment of moderate to severe rotator cuff tendinopathy due to injury with injections of hypertonic dextrose on painful entheses (the ligament and tendon attachments to the bone) resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline.
- A study published in the journal Archives of Physical Medicine and Rehabilitation found that treatment of moderate to severe rotator cuff tendinopathy with injections of hypertonic dextrose (Prolotherapy) on painful entheses (the tendon attachments to the bone) resulted in superior long-term pain improvement and patient satisfaction. (14)
- Another study also published in the journal Archives of Physical Medicine and Rehabilitation, demonstrated dextrose prolotherapy improved in pain, disability, isometric strength, and shoulder active range of motion in patients with refractory chronic non-traumatic rotator cuff disease.(15)
- In the journal, Alternative Therapies in Health and Medicine, (16) doctors presented a case study at the Medical Center at Southwest College of Naturopathic Medicine in Tempe. Here a middle-aged male with a long-term history of untreated shoulder pain received injections into the glenohumeral joint space, the acromioclavicular joint, the subacromial space, and the insertion of the supraspinatus.
- Results: Following 3 sessions of prolotherapy, the patient reported a 90% reduction in pain and full restoration of normal activity. The findings suggest that dextrose prolotherapy may be an effective treatment for chronic shoulder pain and may be an alternative to surgery or other more costly and invasive interventions.
- A March 2019 study in the Journal of Ultrasound in Medicine (17) found that ultrasound-guided prolotherapy with a 15% dextrose solution is an effective and safe therapeutic option for moderate-to-severe acromial enthesopathy and acromioclavicular joint arthropathy.
In this video a general demonstration of Prolotherapy and PRP treatment is given for a patient with repeated shoulder dislocations
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:
- PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
- In the shoulder treatment I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- The patient in this video is not sedated in anyway. Most patients tolerate the injections very well. The treatment goes quickly. However we do make all patients comfortable including sedation if needed.
- This patient in particular come to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
- The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
- With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule and the glenohumeral ligaments are treated.
- PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrate cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
- PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments in this case it was in his anterior shoulder attachments to address the chronic dislocations.
Will these injection treatments help you avoid a shoulder replacement?
Caring Medical Regenerative Medicine Clinics have over 26 years of experience is helping patients avoid surgery. Once we do an examination on the patient we give a clear picture of what he or she can expect from our treatment. Sometimes we are very optimistic that we can offer a lot of help. Sometimes someone comes into our office with shoulder osteoarthritis and rotator cuff damage significant enough that the reality of the situation says surgery and we recommend the surgery. How would you know who you are? An examination usually does a great job determining that. Even if you have been told surgery is the only answer, which we addressed in the research above, we have done countless second opinions where we were able to provide the patient non-surgical options for their shoulder damage.
If you have questions and would like to discuss your shoulder pain issues with our staff you can get help and information from our Caring Medical staff.
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