Shoulder pain is a common problem, unfortunately. Some estimates say up to 33% of all Doctors’ visits for musculoskeletal pain are for shoulder discomfort. Depending on the patient, the usual options for treatment are to:
a) Do nothing
b) Get a cortisone injection
c) See your local Physical Therapist
d) Get imaging
e) Have surgery
Nobody likes multiple choice tests! Tell me what to do Pete! OK, I’ll try my best to suggest (or oppose) these options.
We can already rule this out if you’ve gone to see your MD or physical therapist (which would mean you’ve already done something), but if you’re just sitting at home with an injured shoulder, know that the sooner you get it treated, the quicker it is likely to recover (which, conveniently, also means the less money and time you will have to devote to your bum shoulder). How do I know this? Well, some smart Dutch guys told me so. And some smart British guys. Mechanically, this makes sense because when your shoulder starts to hurt, you stop using it as much, which over time causes the muscles surrounding the shoulder to get weaker, leading to more shoulder pain. Muscles weaken fairly quickly, so the longer you go without using the shoulder, the longer you’ll need to spend strengthening them back up. So doing nothing isn’t the best option in my opinion.
Cortisone is a naturally occurring hormone in our body that, among other things, helps to decrease inflammation. Since local inflammation is typically the source of pain in shoulder problems, the idea of a cortisone injection is to get rid of the inflammation – and therefore – pain in the shoulder. So does it work? Well, sort of. It definitely can help short term, and even has some benefit at one year out. However, those who had just a cortisone injection needed more visits to their primary care physician and more additional cortisone injections (which means more $$$) than those who just had PT. Plus, as I mentioned above, oftentimes weakness in shoulder muscles leads to prolonged shoulder pain, and an injection isn’t going to help that. My advice would be this: If your shoulder hurts a little, skip the injection and try physical therapy. If your shoulder hurts a TON, consider getting a cortisone injection to decrease symptoms short term, then see your PT to ensure long-term benefits as well. In fact, a recent study found that this may be the most cost effective plan for those with moderate to severe shoulder pain!
First of all, it’s important to know that most insurance companies in Minnesota allow you to see your PT directly without first having to see a physician. This is called direct access, and can save you time and money by just coming to us first (you can check if you qualify for this by just calling and asking your insurance company). Secondly, there is TONS of evidence showing how PT can be beneficial for shoulder pain in the short term, and long term. In fact, there are multiple articles showing how patients with shoulder impingement and even rotator cuff tears responded equally well in the long-term between PT and shoulder surgery. Let me reiterate this fact – studies have shown that long term, a majority of patients who just had PT had function and pain levels statistically equal to those who had surgery. Crazy huh? The great thing about PT is that it is our goal to teach you how to manage your condition on your own so that you can avoid surgery, and stay active and healthy for years to come. At the very least, if shoulder surgery is ultimately required, improving motion and strength in the shoulder beforehand can help make the post-surgical recovery process quicker and less painful. This has already been proven in total knee replacement and ACL surgeries, and I can clinically attest to this in shoulder injuries (although I could find no scholarly articles written on this yet).
This is a decision best made by your physician, as physical therapists currently cannot order x-rays or imaging. However, I want you to know two things – first of all, imaging is not the ‘be all, end all’. This study showed that 23% of people without ANY shoulder pain had rotator cuff tears. Another study found up to 40% of people over 50 have asymptomatic rotator cuff tears, and 93% of people over 70 without pain have abnormal changes to the bone structure! They suggest that orthopedists interpret imaging results with caution, as they don’t always relate to pain, so you should take that advice too. Secondly, a brilliant man named Dr. Tim Flynn wrote a great article relating to low back pain and imaging. In short, he explained how imaging may sometimes do more harm than good, as it oftentimes psychologically distresses patients, and doesn’t actually change the treatment approach from a clinician standpoint. Combining this with my previous point – you don’t necessarily NEED an X-ray or MRI, because many of us will have abnormal looking shoulder findings even if we don’t hurt. Let the physician make this call, and potentially save yourself time, money, and psychological distress.
Ahh, the million dollar question. Shoulder surgery is definitely needed in some cases, but oftentimes can be avoided by simply engaging in conservative rehab. A recent study found that about 75% of patients with non-traumatic rotator cuff tears who underwent PT successfully avoided surgery. These orthopedic surgeons found that at 5 years out, patients with shoulder impingement who just engaged in physical therapy functioned statistically equal to those who underwent surgery. Combined with the data above, it’s safe to say that MOST people with shoulder pain can get better without needing surgery by just undergoing some physical therapy. For those who end up needing it, know that trying physical therapy beforehand will likely improve your post-operative prognosis, and could save you time and money in the long run.
I hope this all makes sense, I incorporated a TON of research into this article, so please feel free to click on any of the hyperlinks to read more about all the evidence out there. If you have questions for me specifically, please feel free to contact me at plarson@osipt.com, or give us a call to set up an appointment at 651-275-4706. Have a good one!
– Pete Larson, DPT
FREE PHONE CONSULTATION: (651) 275-4706
