Shoulder Pain and Surgery – A Patient’s Perspective

Shoulder Pain Two Years Later

2013-04-05T16:41:00.000-07:00

It’s a little more than two years ago that I had shoulder surgery in my right shoulder to remove the calcium. I was given a range of 6 to 12 months for full recovery; but warned that the shoulder would never be as good as new.

At the 1-year mark, I was very, very depressed because the shoulder didn’t seem to be any better than before surgery. In addition, I was experiencing daily headaches (that is, every minute of every day I had a headache.) I also had a 1 or 2 migraine headaches every week. I thought that the headaches may be related to the shoulder pain in some way.

Natural Healing of the Shoulder

In the past year, my shoulder has healed somewhat all on its own:

I don’t have to use a sling when I go for a walk. I think I have only used my sling once in the past 8 months.
Sleeping on my shoulder is pain free.
When lying down, I can prop myself up on my elbow.

Certain reaches are now pain free (like reaching something on the floor behind the driver’s seat in the car.)

I can do the breast stroke when I’m swimming (but not for long.) Earlier I was limited to the dog paddle because it kept my arms close to my body. How silly.

Actually, when I look at this list I realize that my shoulder has healed quite a bit on its own this year.

Chronic Complex Pain Doctor

In August 2012 I finally got in to see Dr. Pamela Squire. She deals exclusively with chronic, complex pain. In the 8 months since, she has done the following.

Headaches

First she tried to fix my constant headaches. She tried Botox injections in my forehead, behind my ears and the back of my skull. This didn’t work (but I had a wrinkle-free forehead and looked years younger for 3 months – a nice bonus!)

Then she tried switching medications. I was taking 4 Tylenol #3’s a day to manage the shoulder pain. But she said that Tylenol #3 can cause rebound headaches. So she switched me to the BuTrans 10 patch. It is a narcotic that looks like a square band aid. It is applied on the skin and left for 7 days before changing for another patch. By golly, it worked! After 10 months of constant headaches, they were gone! I had my life back! See more info on BuTrans patch here http://chealth.canoe.ca/drug_info_details.asp?brand_name_id=5721

Neck Pain

Now she is trying to fix my neck pain. I have had neck pain for 28 years since someone jumped on my head when I was in a swimming pool. In the last few years it has become worse and I have been using an anti-inflammatory, Diclofenac, to manage the pain.

She has been injecting Lidocaine into my neck. This is the same freezing that the dentist uses before your dental work. The plan here is to freeze the muscle or ligament. Then it will unclench. The theory is that sometimes they get so tight, so tense, that they never let go. Then you have pain. Freezing them helps them to let go.

Shoulder Pain

She has diagnosed that the bicep sleeve is the area that is still giving me pain. It’s also called bicipital tendonitis. See here for more info http://emedicine.medscape.com/article/96521-overview

She will use Prolotherapy on the bicep sleeve, using her small ultrasound unit to guide her to the correct place to insert the needle (which is very important with the bicep sleeve.) Prolotherapy works by injecting a solution of dextrose (sugar) into the area. Your body recognizes this as a foreign substance and produces inflammation to try to heal it. (The main problem is just an aging tendon. The body doesn’t try to heal that, so we have to trick it into mobilizing its healing agents.)

The reason she stopped working on my shoulder and switched to my neck is that I’m taking Diclofenac, an anti-inflammatory, as mentioned above. But if the Prolotherapy is trying to create inflammation, this is counter-productive.

I have a lot of faith in Dr. Squire since she cured my headaches. She has an arsenal of remedies at hand. If the first one doesn’t work, she has other remedies to try.

My goal is that my neck and shoulders will be 50% better and I will be able to do more activities and use fewer medications when I finish with Dr. Squire. I am confident that this can be achieved.

Mental Health

Depression and anxiety often go together. So, yes, I developed a problem with anxiety also. In the last year, I have been seeing a psychologist to help me deal with these. If you are dealing with chronic shoulder pain leading to mental health problems, I recommend you get help also. Many people try to self-medicate with alcohol or drugs. Or they become angry and bitter and lose friends. And so on. You get the picture… take care of yourself!

Chronic pain is depressing.

I have also been attending a group therapy class based on Marsha Linehan’s DBT (Dialectical Behavior Therapy) model. There are 3 modules with breaks in between; with a total length of 1 year. I am finding this class very useful in dealing with my mental health problems. The module I just finished is on “Distress Tolerance”. The summary of the module is “Getting through a crisis without making it worse” (and dealing with chronic pain is a grade A, top-notch crisis in anyone’s books.) It goes over things like distracting yourself and self-soothing (like taking a hot bath or walking by the seashore and smelling the salt air.) And underpinning all of this is “Mindfulness” – which I don’t really understand yet, but it’s like being in the moment and not worrying about the past or future all the time. You can get a ton of information about DBT at

www.DBTSelfHelp.com

Thanks

I just want to say thank-you to the people who have commented on this blog to tell me how much it has helped them. I had no idea there were so many people with the same problems I have had. I am delighted if I have been of help to you. Thanks. Merci. Gracias. Danke.

Chronic Pain

2012-05-27T17:40:00.001-07:00

This is the ongoing saga of pain in my right shoulder. As I’ve described in this blog, I’ve had 2 arthroscopic surgeries on the shoulder. The latest surgery was almost 15 months ago. I still continue to experience pain every day and I still have to curtail some of my activities so I don’t cause more pain in my shoulder. At this point, I’m not sure what I should do next.

Update on Cortisone Injections

I have had 3 cortisone injections in my shoulder since December. In every case, there was some short-term relief. But each time the pain returned within a couple of weeks. I was never pain-free long enough to attempt to lift heavier weights or resume activities such as bicycling and mowing the lawn. I have concluded that cortisone injections are not going to solve my problem.

Exercising the Shoulder

I realized that I have to be very careful when exercising the shoulder. I found that some exercises were exacerbating the problem. In particular, if I raise my right arm over my head to do something, the result is dramatic:

immediate pain in my shoulder and neck
(usually) a migraine headache starts within 10 minutes

Chronic, Complex Pain

Shoulder pain, neck pain, migraines. This is a very confusing situation. Could the shoulder pain be referred to my neck and head? Or maybe some arthritis in my neck is causing the pain in the other locations?

My family doctor has referred me to Dr. Pamela Squire. She is a specialist in complex pain. Unfortunately, she has a very long waiting-list. But I think this avenue has a good chance of succeeding. My shoulder has no structural problems now (according to X-rays taken in November). And everything I’ve heard seems to indicate that my surgery should have healed in 6 to 12 months. So maybe there is something else going on that is causing all the pain.

Here is the link to a podcast on neuropathic pain (pain of the nerves) by Dr. Squire:

http://www.canadianpaincoalition.ca/index.php/en/help-centre/podcasts

Here are my notes from this podcast (but she had a lot of other good information too)

acute pain

short term pain caused by a specific problem
medication works
the problem resolves (e.g., the kidney stone passes)

chronic pain

long term pain
even after the problem resolves, the pain remains

doctors believe in “phantom limb pain” after a person has had a limb amputated, so it’s strange that some doctors don’t believe in chronic pain
referral of pain - Dr. Squire gave an example of a woman who is pre-disposed to migraines because of her family history. Then she was in a car accident and was experiencing neck pain as a result. A spasm in her neck was a trigger for her migraine. So the doctor had to treat the neck pain to get rid of her migraines.
in diagnosing pain, Dr. Squire looks at other medical factors, psychological factors and family history. This is because, for example, you feel pain more intensely if you are depressed.

Shoulder Pain One Year Later

2012-03-02T16:43:00.004-08:00

It was a year ago today that I had shoulder surgery in my right shoulder to remove the calcium. (See post “Second Arthroscopic Shoulder Surgery - Excision of Calcium and Rotator Cuff Repair”.) This was the second surgery on my right shoulder. I have also had 2 surgeries on my left shoulder. In all, it has been over 3 years since I first saw my family doctor to complain about shoulder pain.

The surgeon had to cut the tendon to get the calcium out. This meant that it would take longer to heal. I was given a range of 6 to 12 months for full recovery. It’s a year later and I’m not sure the shoulder is much better than before surgery. The surgeon was successful in finding and removing the calcium; and an X-ray in November showed no calcium remaining. However, I still have some problems with the shoulder:

I can’t lift heavy objects. It is immediately painful, and remains sore for a few days.
Similarly, I can’t do housework, gardening or exercise which use the shoulder very much. Such things as dusting, wiping a vertical surface, using a rake and doing Pilates all give similar results to heavy lifting.
When I go for a walk for more than 20 minutes, my shoulder starts to ache. I guess it is the weight of the arm hanging down and swinging. I find that using a sling gets rid of this problem. But I never thought I would be using a sling 1 year after surgery!
Sleeping on my shoulder, driving and using the computer cause soreness still (and the longer I do one of those, the sorer it gets).
I am still taking 2 to 3 Tylenol-3 daily to relieve pain.

Steps Taken Since Surgery

Physiotherapy and Exercise

I started physiotherapy with Cameron Bennett, a shoulder specialist, on my right shoulder a couple of weeks after surgery. I did the exercises he gave me religiously until late November. At that time I was heartily bored with them and stopped. I had my range of motion back long before, and all progress from exercising seemed to be at an end.

Cortisone Injections

In December and February, I had cortisone injections in my shoulder.

I wrote about cortisone injections in the post “The Normal Timeline - Conservative Approaches First”. My earlier injections didn’t help, or only temporarily. However, I still had structural problems with the shoulder then. Now that those are gone, Cameron said that I should get 1 or more cortisone injections to settle down the remaining pain in the shoulder. He said:

"The pain is like a fire in your shoulder, and the cortisone is like a blanket. It smothers the fire."
Then he added, “Sometimes, a bit of the fire will kindle up again. More cortisone will smother the flare-up.”
My family doctor concurred and said, “Heavy lifting is like adding oxygen to the fire.”

Injections were given by Dr. Briggs and Dr. Stein of the Stein Medical Clinic. They are conservative in their dosage. Although Cameron recommended 40 mg. as a therapeutic dose, they would only give 20 mg. Dr Stein told me that you can have 100 mg. of cortisone in your shoulder per year. Cameron refers patients to them because they are timely – you can get a cortisone shot the next day if you like. Then he can continue treating the shoulder.

Psychologist

Dealing with chronic pain is depressing. I have considered suicide a few times during my long journey with shoulder pain. But fortunately I have a strong network of family and friends around me, so I will never take that ultimate step.

I visited a psychologist in November. Although I didn’t care for that particular psychologist, she gave me some things to think about. The most important was this:

You can have pain without suffering. That is, you can notice that you have pain and what activity causes it, without becoming despondent about it or obsessing that the pain will never end.

Current Situation

I have returned to doing the physio exercises. Cameron seems very sure that these exercises, and maybe another cortisone injection if needed, will do the trick.

I am somewhat optimistic about the program he has devised. However, after many past disappointments, I am leery of getting my hopes up again.

Comments on This Blog

2012-01-14T12:44:00.000-08:00

I have been delighted by the response to my blog on shoulder pain and surgery. I wrote this blog because I have been through a lot with my shoulder problems and there was a lot of information that I wished I had had at the beginning. I was hoping that I could share my story with you and help you with your journey. In the 8 months since I wrote the first, major portion of this blog, I have received almost 1,700 hits. Wow! I hope this means that I have helped all of you.

By looking at the searches that people use to find my blog, I have noticed some trends that I will discuss below. In general, I would say that you have the same concerns as I do – with getting enough information, with conflicting information and with ongoing pain that doesn’t seem to have an end to it.

Shoulder Pain After Surgery

Many people visit my blog looking for information about pain after shoulder surgery. Some are interested in the pain in the immediate aftermath of surgery – say 1 to 4 weeks. I talk about this at the bottom of my post “Timeline After Surgery”. There is pain after surgery, and it diminishes quickly over the first 4 weeks.

But others are searching for information on pain 6 months to 2 years later. I have to admit that I am still searching for answers on this too. I am 10 months post-op on my right shoulder and 5 months post-op on my left shoulder. Both shoulders still give me pain every day – especially when I sleep on them or if I try to lift something (even just pouring from a 4 litre jug of milk.) I had a cortisone shot in each shoulder in the last month. I will write another post soon to talk about my new experiences with cortisone shots.

How Many Shoulder Surgeries?

I have had 4 shoulder surgeries now – 2 on each shoulder. The first surgeries smoothed off the underside of the acromion and took off the hooked ends. This gave more room for the tendons to move and alleviated some of the pain. However, there were still calcium deposits in the shoulders; which were removed by the second set of surgeries. At this point, my shoulders are fine structurally. No more surgeries are needed, thank goodness.

If your orthopaedic surgeon recommends a second (or later) surgery for you, there is probably a good reason for it. The following posts discuss follow-on surgeries:

Second Arthroscopic Shoulder Surgery - Excision of Calcium and Rotator Cuff Repair
Bi-Lateral Shoulder Pain – Both Shoulders at Once

One person found my blog with the search “I have had 9 shoulder surgeries”. That’s amazing! My sympathies to that person and I hope he or she is finally pain-free.

Information on Specific Practitioners

I debated whether to name the orthopaedic surgeons, doctor and physiotherapist that I have used. You understand that what I say is subjective. I have been careful not to write anything that I can’t defend or that I would be embarrassed for those people to read. My physiotherapist, Cameron Bennett, knows about my blog. I met another orthopaedic surgeon socially who works with Dr. Leith and mentioned my blog to her. So Dr. Leith may or may not have seen it.

Since the post “Which Surgeon?” is quite popular, it seems that this is useful information. Even if you don’t live in Vancouver, the decision process I used in choosing a surgeon can be useful to you.

Bi-Lateral Shoulder Pain – Both Shoulders at Once

2011-10-30T13:39:00.000-07:00

Some of my problems are related to the fact that I have had impingement and calcific tendinopathy in both my shoulders at once. I am right-handed, and the pain started in my right arm. But I had no sooner started to deal with that, then pain started in my left arm too. This led to some problems. The overall timeline is thus:

Which Shoulder To Have Surgery On First?

After exhausting the non-surgical options, my first inclination was to have surgeries on both shoulders at the same time. This would:

result in only 1 period of rehab, and
save money (since I paid privately for the first surgery)

However, the surgeon convinced me to have them done separately. He pointed out that self-care (especially using the toilet) would be difficult or impossible with no arms available. As an incentive, he offered to put me on his public waitlist for the second surgery. After having surgery on 1 shoulder, I agreed with him. Even the simplest things, such as opening a door, require the use of one arm. I used the sling for 2 to 6 weeks – so that is a long, long time to depend on someone else for your every need.

The surgeon recommended that I have surgery on my right arm first. This made sense, since I am right-handed. But surgery on your dominant arm is the most difficult – because it is difficult to do things like eat or dress yourself with the other arm only.

Rehab When One Shoulder Has Not Had Surgery Yet

The ideal situation when you are in rehab after surgery is when the other shoulder is pain-free. But when the other shoulder is waiting for surgery it is painful also.

For the first 2 months after surgery, the shoulder that had surgery (primary shoulder) is more painful. Then there comes a time when the pain is about equal. Some problems arise, such as:

For example, you walk up to a heavy door. Which hand should you use to open it?
Which shoulder do you sleep on?

As you can see, you can’t totally rest the primary shoulder. You will be forced to use it more and more as it heals and the other shoulder gets worse prior to surgery. This causes more pain than the ideal situation (where only 1 shoulder needed surgery.) I believe it also stretches out the length of time for rehab on the primary shoulder.

Physiotherapy for the shoulders includes some movements which are bi-lateral (use both shoulders), such as rows, shrugs and curls. It is possible to do these exercises unilaterally, with a bit of modification. However, keeping the secondary shoulder strong will make that surgery go better. So I have played around, with my physiotherapist’s permission, with using different weights or exercise bands to exercise both shoulders at once. (However, he said that I should use the same weight in each hand when doing shrugs because I am actually exercising the same back muscle.)

How Soon Should the Next Surgery Be?

I have had 2 sets of right/left shoulder surgeries. In the first case, the surgeries were 9 months apart. In the second case, they were 5 months apart.

There are pros and cons to this decision:

pro – you want to get the surgeries and rehab over with and start living your life again
pro – you may have supports in place to ease your recovery (e.g., people willing to take over some routine chores)
con – when one shoulder hasn’t quite healed, you still want to favour it a lot. However, if you have surgery on the other shoulder, the first shoulder has to bear the entire burden – whether or not it is ready.

Overall, I found that having the second surgery too soon extended the overall length of time for rehab and increased the amount of pain experienced and the amount of medication taken. I would recommend having the surgeries more than 6 months apart.

Rehab When One Shoulder Has Not Finished Healing Yet

This is similar to rehab when one shoulder hasn’t had surgery yet – you can’t totally rest the primary shoulder and you have to take care with bi-lateral exercises from the physiotherapist.

For my second set of right/left surgeries, I was still doing physio exercises for one shoulder when I had surgery on the other. Then I had a dilemma – which shoulder to ask the physio to work on in a given session? It isn’t fair to ask him to work on both shoulders, since he only sets aside a certain length of time for an appointment. It turned out that I got more physiotherapy on the second shoulder. This probably delayed further the healing of the first shoulder.

I experienced more pain with the second surgery. This was partly because I could no longer favour the first shoulder. In addition, I got into a “cycle of pain”. My brain experienced pain in both shoulders and somehow the pain intensified because it was coming from both sides. To make matters worse, the bi-lateral pain affected my neck, causing a lot of pain there too. There were days when everything hurt too much and it was hard to get any relief at all.

Summary

It takes a lot of time to recover from 2 surgeries. At times I begin to wonder, "Will this never end?" I have to be strong-willed - keep doing my exercises, celebrate small milestones, and have faith that both shoulders will be okay one day.

Calcific Tendinopathy Revisited

2011-08-28T11:40:00.000-07:00

It’s time to revisit the question of calcium in the tendons of the shoulder (See the post “Shoulder Pain” for a fuller description of calcific tendinopathy.) As you can see from the rest of this blog, I’ve had a roller coaster ride about this. Sometimes I thought I knew what was going on; only to find later that there is another piece of the puzzle and the story is different. What has been particularly frustrating is that I have had differing stories from surgeons and others in the medical community about whether calcium is a problem and what the treatment for calcific tendinopathy should be.

The basics:

calcium is formed in tendons where there is already inflammation. In my case, I had shoulder impingement causing inflammation.
there are probably other factors in the formation of calcium, since everyone with inflammation in the shoulder doesn’t get it.
calcium can be found by x-ray, ultrasound or MRI imaging.
calcium causes pain - “like a rock in your shoe”. The amount of pain depends on the location and size of the calcium. I'm told that some people with calcium don’t experience pain, but I'm sceptical about that.
calcium will eventually be reabsorbed by the body.

Treatment:

cortisone injection to decrease inflammation and allow you to exercise the joint. If the calcium is small, maybe this will be sufficient.
needling to suck out the calcium, only if the calcium is recent. (see previous post on conservative approaches)
breaking up the calcium by needling or radial shockwave therapy. (although there is some doubt if these approaches work.)
arthroscopic surgery to remove the calcium from the tendon. A “shoulder decompression surgery” may remove calcium if it is in the subacromial space. If not, the surgeon must probe the tendon to find the calcium. Then s/he must make a slit in the tendon and push it out.

The Roller Coaster Ride

There were a few things contributing to the roller coaster ride that I have been on concerning the calcium in my shoulders.

1. Our health care system is too costly and there are long waiting lists. So:

Since calcium will eventually be reabsorbed by the body, some medical practitioners feel that nothing should be done about it. They consider that they are doing their job (of containing the demands on the health care system) if they can convince you to wait a few years until the problem resolves itself. One loophole is if you can convince them that the pain is disrupting your life – i.e., you cannot work at your job or take care of your family. But if you are older and retired, medical practitioners are likely to disregard your problems in favour of younger patients. (However if you are vocal enough or can afford to use the private health care system, you can be helped.)
Some medical practitioners will try several non-surgical methods in succession to deal with your calcific tendinopathy rather than proceed to surgery. Inevitably you will try methods with a low success rate. However, this takes time and maybe the calcium will be reabsorbed by your body in the meantime. (Sorry if I am sarcastic here. I've been very frustrated by all of this.)
It is interesting to note that my Mom had surgery to remove a calcium deposit in her shoulder in 1974. There were no long surgical waiting lists at that time. As soon as the X-ray showed she had a calcium deposit, she had surgery. This supports my idea that the delays in proceeding to surgery now are related to an over-crowded health care system.

2. There are different types of orthopaedic surgeons.

There is the generalist “community orthopaedic surgeon” who does everything from hip replacements to setting broken bones in the emergency room. The generalist surgeon who operated on me has certain set procedures that he performs regularly. He says his shoulder decompression surgery works in 80% of the cases. But it doesn’t involve going to look for calcium if it is hidden in the tendon. So it is a matter of luck if your procedure will actually remove your calcium.
Specialist orthopaedic surgeons have more expertise in some areas, and a larger repertoire of surgical procedures they can perform. This gives them more flexibility in responding to your particular problem. However, these surgeons have very long waiting lists (see the post “Waiting Lists and the Private Health Care System”.)

3. Calcific tendinopathy is not well-understood. The research literature I’ve found can’t answer the questions “Why does calcium form for some people and not others?” and “What initiates the reabsorption of calcium by the body?” In addition, family doctors are generalists and don’t normally have a detailed understanding of the various types of shoulder problems (one reason I’ve written this blog!)

I hope this information will help you to deal with your shoulder pain.

Left Shoulder Journey Through Pain and 2 Surgeries

2011-08-17T10:26:00.000-07:00

Latest Surgery

All went well. I was surprised that he didn't find any calcium! It was clear on the X-ray in November .... but calcium can be reabsorbed by the body. However he shaved a bump off the acromion that was compressing the tendon and causing pain, and removed some scar tissue. (This was caused by an inadequate job done on the acromioplasty 13 months ago.) The good news is that, since he didn't have to cut the tendon, rehab will be much faster. For example, I can leave the sling off at home after 3 days instead of 3 weeks; less pain this time too.

The Journey for the Left Shoulder

Until now, this blog has only been concerned with resolving the problems with my right shoulder. At almost the same time, I have been following a similar journey for my left shoulder. As a friend said – it’s a good thing I’m not an octopus … there would be 6 more shoulders to take care of!

Date Procedure/Event

Mar-09 approx. Left arm starts to hurt, pain increases gradually

19-Sep-09 X-ray - calcium found

12-Jul-10 Arthroscopic subacromial decompression and Acromioplasty

23-Jul-10 Physiotherapy on shoulder (post-operative)

to 24-Sep-10

13-Nov-10 Dramatic increase in pain, even at rest. Wearing sling relieves pain.

16-Nov-10 X-ray - calcium found

17-Jan-11 MRI and X-ray done; calcium, AC joint osteoarthritis, possible rim rent partial tear, bursitis found

11-Aug-11 Arthroscopic subacromial decompression and revision Acromioplasty

24-Aug-11 Start physiotherapy on shoulder (post-operative)

A Few New Things I Learned About Orthopaedic Surgery

calcium in your shoulder can be re-absorbed by the body. The calcium that was on the X-ray in November and the MRI in January was essentially non-existent when Dr. Leith probed for it during my surgery last week.

recovering from surgery without a rotator cuff repair is far, far easier and faster than with the repair.

the cryotherapy unit isn’t as effective at reducing the amount of pain medication for a shoulder decompression. With the rotator cuff repair, the cryo unit reduced swelling and, I’m told, reduced the amount of medication I needed to take. However, for this surgery I’m using a similar amount of medication to my prior surgeries before I got the cryo unit.

Introduction

2011-05-10T12:14:00.000-07:00

I decided to write a blog on my shoulder pain and surgeries because there is a lot of information that I wish I had had at the beginning. Specifically, I wish I had known more about shoulder problems in general, the non-surgical options, the health system and what to expect after surgery. I have had contradictory advice; and I’ve had procedures/surgeries done that were recommended by doctors but which failed.

This is my own story of shoulder pain and surgery since January 2009. I started with pain in my right shoulder and later I had pain in my left shoulder too. I tried several non-surgical options. Now I have had 3 surgeries, with another one (the last one, I hope) scheduled. Your problem may not be the same as mine. However, there may be information here that you can use anyway.

Firstly, it is important that you know that I am not a doctor. In fact, I am not in the medical profession at all. Therefore, please check out anything you read here with your own medical practitioner. Also, I may have described some things using improper terminology or mixed things up. Sorry. However, I think the information I want to portray will come through despite these limitations. If you’d like to correct any errors, I’d be thankful (as long as you’re polite, of course.) Also, I express my opinions on some medical procedures and these opinions are definitely not shared by all medical folks.

Secondly, I live in Vancouver, Canada. The health system where you live may be different. I mention specific orthopaedic surgeons, a physiotherapist and a GP who are obviously from the Vancouver area too.

Timeline

2011-05-10T12:12:00.000-07:00

Date Procedure/Event

2007 or so Right arm starts to hurt, pain increases gradually

29-Jan-09 Physiotherapy on shoulder

to 5-May-09

21-Apr-09 Pain in right arm increases dramatically

12-May-09 X-ray - calcium found

15-Jun-09 Cortisone injection - some relief, short-lived

16-Jul-09 Ultrasound

4-Sep-09 Needling of shoulder - failed

30-Oct-09 Arthroscopic subacromial decompression and Acromioplasty

17-Nov-09 Physiotherapy on shoulder (post-operative)

to 27-Jan-10

Mar-10 Started to do more things with shoulder (biking, holding my grandson, etc.) Pain in shoulder
increased. Started taking anti-inflammatories again.

28-Sep-10 Cortisone injection - some relief, short-lived

16-Nov-10 X-ray - calcium found

17-Jan-11 MRI and X-ray done; calcium, AC joint osteoarthritis, rim rent partial tear, bursitis found

2-Mar-11 Arthroscopic subacromial decompression and excision of calcium from tendon

15-Mar-11 Physiotherapy on shoulder (post-operative)
to 2-Jun-11

The Normal Timeline - Conservative Approaches First

2011-05-10T12:02:00.001-07:00

I started having pain in my right bicep in about 2007. After a couple of years of increasing pain, I saw my GP. He said it was likely a problem in my shoulder (pain can be “referred”, i.e., appear to be in a different place than the problem is.) My GP referred me to an physiotherapist and I started on the journey through the “conservative approaches” to shoulder pain. Clearly, one doesn’t start off with surgery at the beginning. Most shoulder pain will be cured by one of the conservative approaches below. It is important to note that going through this route takes time.

As you can see from my timeline in the previous post, if your journey is a long one there are many stops on the journey. It is a good idea to start to make a list like mine. Every time you see a new practitioner, he or she will want to know the history of your problem. My list saved a lot of time in explanations.

Whenever you can, get a copy of the physician’s report or the X-ray report or whatever. Most specialists will send his/her report to your GP instead of to you. You are entitled to request a copy from your GP. Imaging reports are also sent to your GP and copies can be requested.

Also, make notes after every consultation so you won’t forget what was said. Sometimes you’ll have new terms thrown at you. If you write them down (at least approximately) as soon as you leave the doctor’s office, you can look them up on the Internet later.

Physiotherapy

My GP referred me to an excellent physiotherapist, Cameron Bennett. Cameron is from Australia and is a specialist in shoulders. He has a Masters of Musculoskeletal Physiotherapy. A significant portion of his Master's degree dealt with the treatment of shoulder injuries and pain.

Physiotherapists can help your shoulder pain by diagnosing your problem and giving you exercises customized to your diagnosis. Often several sessions with a physiotherapist, if you do your exercises regularly, will be sufficient to alleviate your pain. Physiotherapists can also do some manual therapy and give advice on using medication.

Among other things I learned that:

there are some exercises that can act like a painkiller. There was a period while waiting for surgery that I could do some isometric exercises and stop the pain immediately. It works the same way as stretching after sitting at the computer for a while.
ice applied to the shoulder is very effective at relieving short-term pain, particularly after exercising.
it is a good idea to warm up your shoulder by doing some stretches before doing some heavy exercise such as mowing the lawn.
when you have pain, consider what you have been doing in the last few hours. If you have been inactive, it's time to do some exercises for the joint then put ice on it. But if your pain follows a period of activity, you should rest the joint and put heat on it.

After 3 months of physiotherapy, it was obvious that my problem was going to be more difficult. So Cameron sent me back to my GP with a recommendation that I get X-Rays.

X-Rays

This isn’t a therapy of course, but it is an important step on the journey. In my case, the X-ray showed that I had a large calcium deposit in my shoulder “adjacent to the greater tuberosity of the humerus”. So now I had a diagnosis of my condition – “calcific tendinopathy”. I learned later that the calcific tendinopathy was part of a larger condition called “impingement syndrome.” So there were 2 things causing the pain.

Anti-Inflammatory Medication

About the time I had the X-rays, the pain in my shoulder increased dramatically. I could no longer do activities such as ride my bike or mow the lawn. My GP prescribed anti-inflammatory medication for me. This medication stopped it from hurting all the time – it only hurt when I put stress on the shoulder (e.g., pouring from a jug of milk) and when I lay on it at night. I took this medication for 6 months until I had surgery on my shoulder.

Consultation with the Physiotherapist

With a diagnosis of calcific tendinopathy and sharply increased pain in my shoulder, I started to look around for treatment options. My doctor recommended that I have a cortisone injection in my shoulder. I also heard about radial shockwave therapy and arthroscopic surgery.

I was confused about what to do next. So I booked an appointment with my physiotherapist, Cameron Bennett. He was happy to spend the session discussing the various options. His advice was:

Have a cortisone injection. This relieves pain by reducing inflammation. It wouldn’t get rid of the calcium, but he said that may be OK. Some people don’t even have pain with calcium deposits in their shoulders. He warned me not to do any heavy lifting for a couple of weeks after the injection.
Then wait six months. If the pain has not gone away, have Needling done. This is a procedure which uses a needle to suck the calcium out of the tendon.
Surgery is only a last resort if more conservative approaches fail.
Shock wave therapy uses sound waves to break up the calcium. There is only a 50% success rate, so he dissuaded me from trying this.

Cortisone Injection (aka Corticosteroid Injection)

Cortisone is a powerful anti-inflammatory, so it can relieve the pain from various shoulder problems by relieving the inflammation. The injection should work in 2 to 3 days and the effect should last up to several weeks.

I waited a month to see Dr. Quirke, a GP who specializes in giving cortisone shots. Although the needle is a little scary, it is quite small. Dr. Quirke injected my AC joint (acromioclavicular joint) with Lidocaine at the same time to provide temporary numbing of the area. This is the normal procedure.

I experienced a common side-effect of a cortisone injection called a “cortisone flare”. This a condition where the injected cortisone crystallizes and can cause a brief period of pain worse than before the shot. It lasted a couple of days and the treatment is to ice the injected area.

There was some short-term relief from the cortisone shot, but the relief only lasted for about a week. This is far shorter than I was told it would last. In my opinion, it wasn’t worthwhile to have the injection at all. But maybe others receive a few months of relief. Several practitioners have told me wonderful things about cortisone injections – all I can say is that it never worked for me (I've had 3 cortisone shots to-date.)

As you’ll see later in this blog, this isn’t the only time that I have had contradictory advice about procedures; or have had a procedure performed, on a doctor’s recommendation, and had no relief.

Ultrasound

This also isn’t a therapy and, unlike x-rays, I felt that it wasn’t worthwhile. In my case, Dr. Quirke sent me for an ultrasound simply to measure the size of the calcium deposits in my shoulder. There were other problems existing which weren’t looked for and weren’t found. None of the orthopaedic surgeons I saw later ever asked to see the results of the ultrasound. Therefore, I felt that the ultrasound was a waste of time - I waited for about a month to get the ultrasound done, then another month to get a follow up appointment with Dr. Quirke.

Needling

Next, I was referred by Dr. Quirke for Needling. This procedure is done under local anaesthesia. Using ultrasound imaging as a guide, the doctor inserts a large needle into the calcium deposit and attempts to aspirate, or suck out, as much of the calcium as possible. You can resume activities immediately; there is no rehab period as there is for surgery.

This procedure is not for the faint of heart. The size of the needle is quite scary. And, despite the local anaesthesia, I could still feel the needle somewhat. Unfortunately, the procedure was a failure for me.

When the doctor came in he asked for my "story". As soon as I told him that I had had pain in the shoulder for 2 - 3 years, he said needling wouldn't work. That type of calcium is hard as a rock and he can't force the saline solution in and suck it out. The type of calcium for which needling will work is where the problem is acute - has only existed for a few days or weeks. In that case the calcium is a soup-y consistency and can be sucked out. Nevertheless he did the needling, with the predicted result. When the he finished, he injected some cortisone into the joint.

Since Cameron had advocated Needling, I asked him about my failed result. He responded that Needling can help even when the calcium is hard, by breaking it up. Then the smaller pieces of calcium are more readily absorbed by the body. He added that it also depends on the classification of the calcium.

Other Conservative Approaches that I Didn’t Try

Radial Shock Wave Therapy

Radial Shock Wave Therapy (RSWT) directs a high-energy sound wave at the calcium deposit. It works by increasing the metabolic activity around the calcium to stimulate the re-absorption of the calcium and by stimulating the body’s natural healing process. Usually there are multiple (3 to 6) sessions, about a week apart.

One orthopaedic surgeon referred me to a physiotherapist for 6 sessions of RSWT. However, another orthopaedic surgeon and my regular physiotherapist said that the success rate of this procedure is low. In fact, the physiotherapist pointed out that a rotator cuff tear (which I had also been diagnosed with at the time) is a contra-indication for RSWT.

Prolotherapy

Prolotherapy uses a dextrose (sugar water) solution, which is injected into the ligament or tendon where it attaches to the bone. This causes a localized inflammation in these weak areas which then increases the blood supply and flow of nutrients and stimulates the tissue to repair itself. It is used to treat many different types of musculoskeletal pain, including chronic tendonitis. Usually 4 -6 treatments are needed, but it could be more.

One orthopaedic surgeon told me that prolotherapy does not work.

Platelet-Rich Plasma Therapy

This is similar to prolotherapy but instead of injecting dextrose, platelet-rich plasma is injected. The doctor draws the patient’s blood and spins it down in a centrifuge to concentrate the platelets into a much higher amount, approximately five times normal. Platelets have granules inside them that have growth factors that cause the ligaments and the tendons to heal.

One orthopaedic surgeon told me that platelet-rich plasma therapy is a better procedure than prolotherapy. In my case, he said it may or may not work.

Shoulder Pain

2011-05-10T11:41:00.000-07:00

The shoulder is a very complex joint. It has the greatest range of mobility of any joint in the body. This increased motion comes at the expense of a decrease in stability in the joint, requiring the muscles and tendons to play a more critical role in maintaining joint integrity. Injuries, overuse and repetitive movements, the shoulder characteristics you were born with, and biomechanical weakness can all lead to problems in the shoulder and, ultimately, pain. Below I discuss 2 shoulder problems that have affected me.

Impingement Syndrome

Impingement syndrome is a catch-all term to describe pinching of the tendons and bursa of the rotator cuff between the bones of the shoulder. Between the acromion (the tip of the shoulder blade or scapula) and the humerus (the upper arm bone), there are several muscles and tendons that form the rotator cuff. The tendons must move freely, but when the space is compressed (or “impinged”) there is pain and inflammation.

Impingement can be caused by various things. As we get older, our tendons get thicker. It’s like a rubber band that you stretch and release many, many times – after awhile it gets a little shredded at the edges. So it is with our tendons. When the tendon is thicker, it is squeezed in the space that is available. That is why this condition affects people over 40 most often.

http://www.aafp.org/afp/980215ap/fongemie.html

Types of Acromion: Type I (flat), Type II (slanted),

Type III (hooked)

Impingement can also be caused by the shape of your bones such that they have less space than usual. For example, I had a “hooked acromion”. The underside of the acromion can be flat, slanted downwards or hooked (see picture). The latter 2 shapes decrease the space available for the tendons to slide and cause impingement.

Finally, impingement can be the result of dysfunctional shoulder biomechanics, and is exacerbated by excessive motion or long periods of compression.

More information can be found on the Internet, for example:

http://orthopedics.about.com/cs/rotatorcuff/a/shbursitis.htm

Calcific Tendinopathy (aka Calcific Tendinitis)

Calcific tendinopathy is a disorder where calcium deposits are found in any tendon of the body, but most often in the rotator cuff of the shoulder. It causes pain, particularly when lifting the arm or sleeping on the affected shoulder, and is usually found in adults who are 40+ years old.

There are 3 stages of calcific tendinopathy:

precalcification, when cellular changes occur in the tendon.
calcific, when calcium deposits form. This is the painful stage. After time, the calcium is re-absorbed by the body, which is particularly painful.
postcalcific, when the tendon has returned to normal, perhaps with some scar tissue.

I was told by some doctors that calcific tendinopathy does not need to be treated, because it resolves itself eventually. Or one should treat the symptoms only; such as using analgesics to control pain and ice to control inflammation. I was also told that there are many people with calcific tendinopathy who have no symptoms at all.

Well, none of that was true in my case. My symptoms lasted for 4 years until I finally had the calcium deposits removed by arthroscopic surgery. The pain in my arm prevented me from doing many ordinary activities. Initially, I had to stop heavy use of my arm such as mowing the lawn and washing windows. As the pain progressed, I could no longer ride my bike or other medium-heavy use of the arm. Finally, I couldn’t even do light activities such as using the computer mouse. By the time of surgery I was taking a small dose of narcotic medication and applying ice daily. I was also having a very hard time sleeping on the affected side.

More information can be found on the Internet, for example:

http://orthopedics.about.com/od/rotatorcuff/a/calcific.htm

http://www.shoulderinstitute.co.za/calcific_tendinitis.php

Imaging of the Shoulder

2011-05-10T11:34:00.000-07:00

If physiotherapy does not solve your problem, the next step is to get an X-ray or other image of your shoulder. This will give your GP or surgeon the information necessary to diagnose the problem and plan your treatment.

Although I have heard otherwise from imaging clinics, you are entitled to a copy of the report and/or image. Often clinics will provide the image on a CD. Before taking the CD to my doctor, I made a habit of copying the information to my computer. Then it was available when I saw a different doctor.

X-Rays


X-ray of my left shoulder with calcium on the head of the humerus, AP projection - magnified

This is the most common type of image, one we are all familiar with. For shoulders there are 3 positions:

antero-posterior (AP) – the classic pose where the patient faces the x-ray tube.
lateral scapula – patient turns 90º so the x-ray tube points at the side of the shoulder.
axial – patient sits on a stool and leans over the end of the x-ray table. The arm is stretched over the table. The x-ray beam is directed downward through the arm pit.

Ultrasound

Shoulder ultrasound

High-resolution ultrasonography bounces sound waves off objects to image them. Most women who have been pregnant have had an ultrasound image taken of the foetus in the womb.

For a shoulder ultrasound, the patient sits or lies on a table, the technician puts gel on the skin and places a probe on the shoulder. When s/he moves the probe around, the image on the computer screen shows the bones and tissues inside the shoulder. Ultrasound images are very detailed and, since they show muscles and tendons too, they give the doctor more information for a diagnosis. Images can be printed to share with your surgeon or physiotherapist.

MRI

Magnetic resonance imaging (MRI) is a test done with a large machine that uses a magnetic field and pulses of radio wave energy to make pictures of the shoulder (or other body part). It can visualize the entire shoulder -- including bones, ligaments, cartilage and the rotator cuff. Therefore, it provides a more global assessment of the shoulder than an ultrasound can.

MRI machine

For an MRI test, you are placed inside the magnet so that your shoulder is inside the strong magnetic field. The most noticeable thing about the test is the loud noise. When it is taking the magnetic image, it makes a jack-hammer-like noise. There's about 5 minutes of a slow jack-hammer, then 5 minutes of a faster one, then faster, etc. In between are short silences and other weird noises. The MRI Tech had kindly given me a choice of music to listen to, but it was hard to hear the music over the noise. The test takes 25 minutes and you have to stay perfectly still to avoid blurring the image. Basically I just closed my eyes, zoned out and ignored the noise.

Pictures from an MRI scan are digital images that can be saved on a computer storage device (such as a CD.)

Waiting Lists and the Private Health Care System

2011-05-10T11:22:00.000-07:00

Note that this section will be most pertinent to people in Canada, or those with similar medical insurance systems to ours.

This is an area that I really wished I had had some guidance before I embarked on this journey. Once the GP told me that surgery was the only option, I thought it would be fairly straight-forward. Not at all. First I had a rude awakening about the length of waiting lists for orthopaedic surgeons. When waiting lists proved unacceptably long, I had a lot to learn about navigating the private health care system.

Waiting Lists for Orthopaedic Surgeons

The GP who had given me a cortisone shot and referred me for needling had reached the end of alternatives to offer me. He suggested that I find an orthopaedic surgeon with the shortest wait listing and have arthroscopic surgery done. This surprised me. I thought that GP’s normally referred their patients to specialists whom they trust, instead of leaving it to the patient to find a surgeon.

Initially, I made a list of orthopaedic surgeons in Metro Vancouver and starting calling their offices to see how long their waiting lists were. I learned a few things from this exercise:

if you even think that you may need surgery, put your name on the waiting list for your preferred surgeon.
it was very difficult to put together a list of orthopaedic surgeons. Later I learned that there is a website here https://www.cpsbc.ca/node/264 where you can search for contact information for specialists of various types who are members of the College of Physicians and Surgeons of BC.
you have to ask how long is the waiting list for a consultation; then how long is the waiting list after the consultation until surgery (i.e., there are 2 waiting lists - don't be fooled by being given only the surgical waiting list time.) However, some surgeons will not share the length of their waiting lists.
consultation waiting lists ranged from 7 months to 2 years. Surgical waiting lists after consultation ranged from 4 months to a year. (So the whole thing is 11 months to 3 years.)
later I learned that there is a website here http://www.health.gov.bc.ca/swt/ where you can research the actual waiting times for various specialists in BC for certain procedures. It gives the median wait time in weeks for the latest 3 month period. See the Caveats later in the section before relying too heavily on this data.
some surgeons, though listed as practising, do not accept new patients at all because their waiting lists are too long. Also, some surgeons have retired but are still listed as practising.
I found one surgeon whose secretary told me that I could have surgery in only 2 months. When I later called back to book a consultation, the secretary disclaimed all knowledge of this claim and said the surgery would be at least 12 months.
I tried calling orthopaedic surgeons who practise outside Metro Vancouver. Their waiting lists were even longer than those in Metro Vancouver. And I found that surgery in another province is not possible – they have a different Provincial medical insurance system and will not take out-of-province cases.

After researching waiting lists for orthopaedic surgeons, I was very discouraged. Since I had already spent 9 months going through the conservative approaches to my problem (which followed a 2 year period where I was just hoping it would go away), my shoulder was extremely sore. I was taking a mild narcotic for pain and an anti-inflammatory medication. Still, I couldn’t lift my arm up more than half way. I couldn’t bear the thought of waiting a minimum of a year for surgery. At this point I decided to pay for surgery so I could have quick relief.

Caveats About Waiting Lists

There has been a lot of focus on wait times for surgical procedures as a measure of the effectiveness of the Health Care system in Canada. However, it is my experience that wait times are bogus - they are manipulated by the surgeon's secretary. The published wait time starts after the surgeon accepts you for surgery. So it doesn't include the long wait time just to see the surgeon for a consultation (7 months to 2 years, I found). There is no reason why a consultation can’t be scheduled within a month – it is just a meeting, after all. But I think consultations are delayed arbitrarily to make the surgical wait lists look better.

Also, if you hesitate about accepting a date for surgery (e.g., you've planned a vacation then) the secretary may kick you off the waiting list altogether. S/he doesn't want the wait time to be lengthened just because you want to delay a week or so.

Some surgeons won't even accept new patients. Their wait list for consultations is too long already. How is that reflected in their wait time for surgery?

I was referred to a new surgeon in town. I found out later that he doesn't even have operating room times at the hospital yet. I guess he picks up unused spots on the OR calendar. What does this say about his waiting list?

Private Health Care

Because waiting lists for elective surgery are so long in Canada, we have a flourishing private health care system. Neither the Provincial medical insurance system (MSP), nor the Extended Health insurance that many people have through their employers, cover private health care. The only break you get financially is that you can claim these medical expenses as deductions on your income tax return.

I am ambivalent about the ethics about using private health care. On the one hand, it is only available to those who can afford to pay. (Not that you have to be wealthy to use this system. When you are faced with a year or more of excruciating pain, it can be an easy decision to forego the vacation or bathroom renovation in order to have surgery.) On the other hand, people who use the private health care system leave extra spots on waiting lists for people using the public health care system. And surgeons are not able to keep busy doing surgeries in over-crowded Operating Rooms (they are given too few time slots on the OR calendars), so they spend their extra time at private clinics.

Private Health System - Consultation

It is possible to have a private consultation with a specialist, such as an orthopaedic surgeon, then get on his or her regular waiting list for surgery. I believe that all specialists offering their services at private clinics also work at public hospitals. And, since the waiting list for the consultation is often greater than the waiting list for the surgery, it can save you a lot of time to do this.

A consultation is a meeting with a surgeon where you tell him or her the history of your problem (e.g., shoulder pain) and what procedures you have had performed to-date. Then the surgeon examines your shoulder and does various tests to check your range of motion and pain levels. S/he examines any imaging (X-rays, MRI’s, etc.) you have had done and may order extra imaging if necessary. Then s/he develops a plan of action with you. If surgery is recommended, the surgeon or the clinic will give you an estimate of the cost to have it done with them. At this point you can discuss being added to the surgeon’s “MSP wait list” to have the surgery done in a public hospital.

In October 2009, I had a consultation with Dr. Kokan at False Creek Surgical Centre about pain in the my right shoulder. That consultation cost $475 plus tax for about 20 minutes. In February 2011, I had a consultation with Dr. Leith at the Specialist Referral Clinic about pain in both right and left shoulders. That consultation cost $750 including tax for about 45 minutes (I had been quoted $500 for 30 minutes for consultation on 1 shoulder.) By the way, Dr. Leith is a highly recommended surgeon who doesn’t accept patients for consultation in his public “MSP” practise because his waiting list is already too long. However, if you have a private consultation with him, you are able to get onto his public waiting list for surgery.

Private Health System - Surgery

After having a private consultation with a surgeon, you may decide to have surgery privately or in a public hospital. The private surgery clinics have some nice touches, such as a private room to wait in before surgery instead of a ward. However, the quality of medical care in both venues is excellent and should not be a deciding factor. Also, since all surgeons (I believe) offering private surgery also offer surgery in public hospitals, you have access to the same surgeons for both options. Even the anaesthesiologists and nurses in the private clinics work in the public hospitals too.

The deciding factor for surgery will probably be the waiting list. I found that waiting lists are about 4 months to a year for surgery after you have had the consultation. If you are in a lot of pain, and your everyday activities are severely impacted, you may decide to have the surgery done privately.

In October 2009, I had an arthroscopic shoulder decompression surgery by Dr. Kokan at False Creek Surgical Centre. That surgery cost $4,800 including tax. In February 2011, I had an arthroscopic excision of calcium and rotator cuff repair with Dr. Leith at Cambie Surgery Centre. That surgery cost $6,800 including tax.

Which Surgeon?

2011-05-10T11:05:00.000-07:00

So far, I have been talking about waiting lists as the primary criteria for choosing your surgeon. This was my mindset when I first started thinking about surgery. And, to be fair, I think all the surgeons below that I came into contact with are highly qualified and excellent surgeons. The difference was their approach to my shoulder problems and their experience level.

In summary, the criteria for choosing a surgeon that I came up with are:

waiting list
specializing in shoulder problems
high level of experience
compatible approach

More information can be found on the Internet about surgeons, for example:

https://www.cpsbc.ca/node/264 allows you to search for contact information for specialists of various types who are members of the BC College of Physicians and Surgeons of BC. I would not trust a surgeon who is not a member of this college.

http://www.ratemds.com/social/ allows people to give their opinions on surgeons and GP’s. I found this site of some use. Like other internet sites with people’s opinions, it is quite subjective. The things that some people complain about would not bother me.

Note that the following orthopaedic surgeons practise in the Vancouver area. There may be some points of interest here in evaluating surgeons near you.

Dr. Peter Kokan

I was assigned Dr. Kokan when I booked an appointment at False Creek Surgical Centre about pain in my right shoulder. I found him to be very easy to talk to and sympathetic about my problem. He recommended shoulder decompression surgery to alleviate the impingement in my shoulder. He told me later that this is the standard surgery for shoulder problems of my type, and it works 80% of the time. Even though I had come to him complaining of calcium deposits, this surgery does not specifically deal with calcium. If calcium is found in the subacromial space, it is removed.

Surgery was performed in October 2009. The surgery and rehab went well. The excruciating pain in my shoulder was relieved. However, after 4½ months pain in my right shoulder returned. I had a follow-up visit with Dr. Kokan. He told me that I may be having a “recurrence of inflammatory tissue” and to limit my activities to reduce the pain. He opposed additional surgery. In September 2010, 11 months after surgery, I saw Dr. Kokan again to complain about pain in my right shoulder. He gave me another cortisone shot in my right shoulder, which gave relief for only a few days.

After the right shoulder surgery, I was added to Dr. Kokan’s waiting list for left shoulder surgery for the same problem. This was performed in July 2010 (8 months on his waiting list.) Again, after 4 months the pain returned. At that point, X-rays were taken and significant calcium deposits were found in both shoulders. I feel that both surgeries by Dr. Kokan were limited successes.

A few months later I consulted Dr. Leith about my shoulders. He read the operative reports from Dr. Kokan and noticed that Dr. Kokan had not even looked for calcium. (The calcium was under the tendon so had to be sought out). Dr. Leith wasn’t surprised that I was still suffering pain in my shoulders because of the presence of calcium. He even said “I should get my money back!” from Dr. Kokan. He was quite angry that a surgeon would miss this important item. As mentioned elsewhere, there is a lot of disagreement among practitioners about whether calcium in the shoulder is the cause of pain and whether it should be removed.

Dr. Danny Goel

After the limited success of my first 2 surgeries, I returned to my GP for a referral to an orthopaedic surgeon who specializes in shoulders. He referred me to Dr. Leith. However, we found that Dr. Leith wasn’t accepting new patients because his waiting list was too long already. Dr. Leith’s office referred me to Dr. Goel.

Dr. Goel is young, practising for about 2 years after his surgical residency. He specializes in shoulder problems. He had recently returned to Vancouver so his waiting list for a consultation was short. However, I found out later that he doesn’t have surgery time at the hospital – he gets times in the OR “here and there”. So his surgical wait list was several months.

After examining my shoulder he was concerned that I may have a rotator cuff tear. So he ordered an MRI. I was not happy with Dr. Goel’s “bedside manner”. He was 25 minutes late for my appointment, which was his first for the day, so he may have been trying to make up time. I felt rushed. He didn’t even look at the X-rays I had had done the previous week that showed calcium deposits in both shoulders. Nevertheless, I stayed with Dr. Goel because bedside manner isn't the most important thing in evaluating a surgeon.

I waited 2 months for an MRI then returned to Dr. Goel. He recommended radial shockwave therapy on both shoulders to break up the calcium. He said a cortisone injection in the left shoulder and surgery on both shoulders were other possibilities. I said I would think about it, knowing that I had a consultation for a second opinion with Dr. Leith the following week.

I was unhappy with Dr. Goel’s diagnosis. I had already heard that radial shockwave therapy has a low success rate. I learned later that it is contra-indicated if you have a rotator cuff tear (and my MRI showed a small rotator cuff tear in my left shoulder.)

At this point, I added a criterion to my decision process for a surgeon. I wanted a surgeon with a high level of experience.

Dr. Jordan Leith

Both my GP and my physiotherapist had recommended Dr. Leith to me. He is a highly-experienced orthopaedic surgeon and he specializes in shoulder problems. He doesn’t accept patients for consultation in his public “MSP” practise because his waiting list is already too long. However, if you have a private consultation with him, you are able to get onto his public waiting list for surgery.

I was impressed with Dr. Leith’s manner and attitude. He is very knowledgeable and impressed me with his discussion of my prior surgeries and the advice of Dr. Goel. Dr. Leith felt that the calcium in my shoulders was almost certainly causing the pain. “It’s like a rock in your shoe.” He recommended a revision decompression surgery (to clean up any scar tissue and review the work done by Dr. Kokan), followed by probing the tendon for calcium and removing it if possible.

Surgery was performed in March 2010. He found and removed a lot of calcium from under the tendon. See section "Video" for a look through the arthroscopic camera of this. As of the time of writing (4 months post-surgery), rehab is going well. I will have to wait until about 6 months post-op to determine if the removal of calcium has cleared up the problem.

Arthroscopic Shoulder Surgery - Shoulder Decompression

2011-05-10T10:50:00.000-07:00

Arthroscopic shoulder surgery is much less invasive that open surgery. Two or three small incisions are made in the shoulder to insert the arthroscope (a camera) and the instruments. A saline solution is inserted into the shoulder to make space to view the structures and to wash away the resulting bone and calcium fragments.

Shoulder Decompression is a surgery where the underside of the acromion is shaved off, making more room for the tendons to slide back and forth. This eases the shoulder impingement. In my case, the surgeon also performed an acromioplasty. This procedure shaved off the hooked end of my acromion, also giving more space for the tendons to move.

Pre-Op

Before surgery there are 2 things asked of you by the hospital or surgical centre. They are; an ECG (to check for problems with the electrical activity of your heart) and a sheet of questions about your health, medical conditions you may have, and any previous surgeries.

You may not eat or drink anything from midnight the night before the surgery. This is very important – they will cancel surgery if you have broken this rule. One anaesthesiologist asked me, “What did you have for breakfast this morning?” The right answer is, “Nothing.”

Day of the Surgery

The morning of the surgery is a good time to have a shower. You will not be allowed to take a shower for 4 to 7 days after surgery. Also, it is a good idea to wear a loose-fitting shirt that closes down the front. Since your shoulder should be immobilized, you won’t want to wrench your arm into the sleeve of a shirt that goes on over your head.

It is mandatory that you have a responsible adult take you home after surgery and stay with you the rest of the day. The hospital or clinic staff will call him or her when you are almost ready to go. It is ok for that person to take you home in a taxi, but public transport is not allowed.

General Anaesthetic

Arthroscopic surgery is done under a general anaesthetic. i.e., they put you to sleep. The anaesthesiologist will see you before the surgery to discuss medication options and any prior reactions to anaesthesia. After you are unconscious, s/he will put a tube down your throat to take control of your breathing. The breathing tube will be gone before you wake, of course. But you may have some soreness in your throat.

The Surgery Itself

http://www.csc-surgery.com/gallery04.php

Using the monitor in arthroscopic surgery. From

Cambie Surgery Centre photo gallery

Your surgeon will also see you before surgery to answer any questions you have and to mark your shoulder (you wouldn’t want the wrong shoulder to be worked on!) You will probably be asleep before the surgeon enters the operating room. Arthroscopic surgery is well-understood these days so you don’t have to worry. I was told that, from the surgeon’s viewpoint, it’s a little like playing a video game. The camera shows the inside of the shoulder and the instruments on a large monitor. S/he manipulates the instruments by looking at the monitor.

Sling and Dressing

After surgery there will be sterile strips applied to the portals (the incisions made in your shoulder.) Over this will be a large dressing to catch any discharge. (They fill the subacromial space with a saline solution for the surgery and some may leak out later... don’t worry; the discharge isn’t bloody.) Your instructions will tell you when you can remove the dressing and take a shower – maybe 4 to 7 days.

You will also be wearing a sling when you awake. Your post-op instructions will also tell you how long to wear the sling. For a decompression surgery, you may have to wear it for a week or two. If there is a rotator cuff tear, you may have to wear the sling for 4 to 6 weeks. At the beginning, the sling is there to immobilize your shoulder so you don’t aggravate it. Later (especially when you wear it for 6 weeks) the sling is protective – it tells others not to knock into you.

Follow-up Visit(s) with Orthopaedic Surgeon

The surgeon will schedule an appointment with you in his/her office a week or two after surgery. This appointment is to ensure that the healing is going well and there is no infection. Of course, if something doesn’t seem right after the surgery, you should call the surgeon right away and not wait for this follow-up appointment. The surgeon may also schedule an appointment with you at 3 months post-op to ensure you are still on track.

Timeline After Surgery

2011-05-10T10:40:00.000-07:00

This is another area where I really wished I’d had some guidance before I embarked on this journey.

First Day

When you get home from the hospital or clinic you will feel pretty groggy from the anaesthetic. It can take a day or two to get the anaesthetic out of your system. In addition, you will be given some pretty strong medication for pain. This will also make you a little groggy. Rest quietly at home for the rest of the day. Lie flat if you feel dizzy or light-headed. Nausea and vomiting are a common side-effect after a general anaesthetic, however the drugs have improved over the years so fewer people will experience this.

Drink lots of water and non-citric juice for the first 4 to 6 hours after surgery. Later you can have a light meal (e.g., soup, jello or toast.)

Things to avoid after surgery:

milk for 24 hours
alcohol for 48 hours
smoking after surgery – it may impair healing, induce coughing and, as a result, increase chances of bleeding post-op
do not operate machinery or a vehicle for 24 hours
do not sign a contract in the first 24 hours

The Sling

Wear the sling when you are up and about and when you go to bed. When resting, you can take your arm out of the sling to exercise the elbow and hand to prevent stiffness. Be very gentle and keep your elbow by your side.

Sleeping With a Sling

For the first several days you should sleep with your sling on. This prevents you from moving your arm away from your side, or into some awkward position where you could hurt yourself. When lying on your back, you may have a bit of pain because the arm drops back to the bed. If so, put a thin cushion under your elbow to prop up the arm. Usually I was able to turn over and sleep on my unaffected side (a nice break!) But other times, my shoulder was too sore so I could only sleep on my back.

Exercises After Surgery But Before You Start Going to the Physio

Doing the pendulum exercise

Starting on Day 2 post-op, it is important to start to get your arm moving gently. Every day, do some pendulum exercises (see http://sportsmedicine.about.com/od/surgeryrehab/qt/PendulumCircle.htm) and passive range-of-motion exercises (where you lift your affected arm in front using your good arm). At first, you probably won’t be able to move your arm very far. But it is important to start the exercises so you don’t get “frozen shoulder.”

Meds

I was prescribed Oxycocet after my surgery for pain relief. This is a strong narcotic drug. Besides helping with pain, it made me feel mellow and, at higher doses, a little spaced out. I learned quickly that it is best to write down the times that I took the prescribed doses. Otherwise, it would be easy to forget and take doses too frequently.

This medication takes about an hour to become maximally effective. I was warned that I should “stay on top of the pain”. If my shoulder was hurting badly, I had waited too long to take my medication. Then it is hard to get the pain under control again. I even set my alarm for the middle of the night to take a prescribed dose. I reasoned that was better than waking up in agony because of a missed dose.

Immediately following surgery my dosage was 2 tablets every 6 hours. However, the nurse for my second surgery gave me a tip; it is better to take 1 tablet every 3 hours. This keeps the concentration in your body at a more constant level. This worked very well.

After a day or so, I started increasing the length of time between doses to 3.5 hours, 4 hours, etc. Eventually, I started taking a ½ tablet for my dose. Then I was ready to back off to my second medication, Tramacet. This is also a narcotic drug, but not nearly as strong as Oxycocet. I started replacing ½ an Oxycocet tablet with 1 Tramacet for 1 dose in the day. Then I replaced more doses with Tramacet until I was off Oxycocet altogether. In a similar manner, I decreased the dosage of Tramacet until I was drug-free. It is important to gradually wean yourself from these drugs – stopping suddenly can cause withdrawal symptoms.

Icing

Applying ice to your shoulder can relieve inflammation. This helps to control pain and can decrease the amount of medication that you need. See post "Second Arthroscopic Surgery - Excision of Calcium" for information on the cryotherapy unit, which provides icing for several hours at a time.

You Need Someone to Help You

Besides driving you home from the hospital, it is invaluable to have someone to help you in the first few days after surgery. You may need help with:

going up and down stairs if you’re feeling groggy
making meals and cleaning up afterwards
cutting your food (since you’re wearing a sling)
taking you for a walk around the neighbourhood
making ice packs for you
giving you a sponge bath before you’re allowed to shower
washing your hair in the sink (I couldn’t stand to wait 4 days until my first shower)
giving you a shower (since you only have 1 arm to work with and are feeling sore)
companionship (since you can’t get out much at this time)

Do As Much As You Can As Soon As You Can

My strategy was to do as much as I could, as soon as I could. Every little step towards independence is important. I wanted to use my muscles and my brain to start regaining my strength and clarity of mind.

Here is a chart of when I was able to do some activities after shoulder decompression surgery:

Activity	Week 1	Week 2	Week 3	Week 5	Month 3	Month 4
Walk around the neighbourhood	Day 2
Sleeping better	Day 3
Did the laundry	Day 4
First shower	Day 5
First public appearance	Day 5
Leaving sling off at home	Day 6
Solo trip to coffee shop	Day 7
Can type with both hands		Day 8
First solo shower		Day 8
Got rid of sling		Day 10
Can wash dishes and take out garbage		Day 11
Can wear shirt that pulls on over the head		Day 12
Follow-up appointment with surgeon		Day 14
Driving solo now		Day 14
Started physiotherapy			x
Can partially lay on affected shoulder			x
Started replacing Oxy with Tramacet			x
Finished taking Oxy				x
Can back out of driveway				x
Can sleep on affected side (no pain)				x
Last physiotherapy appt					x
Can lift my grandson now					x
Can ride my bike now						x

Post-Surgery Physiotherapy

Your surgeon will probably recommend that you start physiotherapy 2 or 3 weeks after surgery. While this is not mandatory, it is a good idea because you want to get back your range of motion and the strength in your shoulder as soon as possible. Your physio will guide you through this – introducing each step when s/he feels you are ready.

If you have had surgery to repair a rotator cuff tear, the physio will move at a slower pace. For the first 5 weeks, movements will be assisted by the physio and all of them are done under his/her supervision.

It is important to do the exercises that your physio assigns every day. You can only increase your range of motion and strength a little at a time. A weekly visit to the physio won’t do the whole job. When people remark on my dedication to the physio exercises, I reply, “Pain is a good motivator.” I think that my speed of recovery (see the section “Do As Much As You Can As Soon As You Can”) is mostly a result of this diligence about doing the exercises.

How Long Does the Pain Last?

I would say that there are 5 periods for the pain:

On the first day, the freezing in your shoulder from the operation wears off after 4 to 6 hours. At that point, you'll feel the pain kick in. However, they send you home with a prescription for Oxycocet or an equivalent strong pain medication; and the time when you are allowed to take your first dose. When I followed the dosing recommendation, I wasn't bothered too much when the freezing came off.
After surgery until week 3 (to be precise, Day 22), I took Oxycocet because the pain was pretty strong. Of course, the pain tapered off over this time and I increased the time between doses from 3 hours to 8 hours.
From 3 to 5 weeks post-surgery, I took Oxycocet for some of my doses, and Tramacet for others. At this point I wasn’t wearing my sling, I could drive and, by 5 weeks, I could sleep on the affected side. So the pain had decreased considerably. However, if I used my shoulder a lot (I tried swimming, for example) it hurt quite a bit.
From 5 to 20 weeks post-surgery I took Tramacet for pain relief. At 20 weeks I could do most activities again. However, if I wanted to do something that used the shoulder a lot (such as bicycling or mowing the lawn) I had to warm up my shoulder with some stretches first. This decreased the soreness from these activities.
Sorry, I can't tell you how long it takes until the shoulder is completely back to normal. I've never got that far. (After the first surgery, there was calcium and pain remaining. And I'm only at 4 months post-op for the second surgery.) However, I hear that it is 6 to 12 months until your shoulder is as good as new.

Dealing With an Increase in Pain

With each of my surgeries, there has been a sudden, temporary increase in pain some time during the healing process. Maybe I've been a little too enthusiastic with my exercises from physio or something. I find the following has helped to deal with this.

reduce activities using the affected shoulder
wear the sling for a while
put ice or heat on the shoulder
do the pulley exercises (gently)
increase the dose of medication a bit (notice this is my last resort)

Complications and Problems After Surgery

2011-05-09T17:47:00.000-07:00

Constipation

The medication that was prescribed to me for pain relief was Oxycocet. It is very strong and is known to be constipating. However, I had forgotten this side-effect, so I did not take stool softeners or Metamucil as a precaution. Five days after surgery I had an attack of Ischemic Colitis. This is an inflammation of the colon caused by an interruption of the blood supply to the colon. The gastroenterologist who treated me is pretty sure that it was caused by my severe constipation. I was taken to hospital in an ambulance and spent 5 days in hospital for this ailment. This was probably a fluke; but it is a caution for you to ensure you don’t get constipated if you’re taking Oxycocet (or Oxycodone.)

Trouble Sleeping

In the first few days after surgery, even though I was groggy from the anaesthetic, I had a difficult time sleeping. This was because:

I was uncomfortable with my arm in a sling
it was hard to turn over (from my back to/from the unaffected side of my body)
maybe an after-effect of the anaesthetic

Strong Reaction to Physio Exercise

At one of my earlier physio sessions after surgery, I guess I did the exercises a little too enthusiastically. By the end my shoulder hurt a lot. By the time I got to my car, I had a migraine. I emailed with my physio about this and he replied, “It may be a strong reaction to general exercise for the shoulder and some hypersensitivity in the neck (and probably shoulder).” So I took it easy on the exercise for a few days and it was OK.

Feeling of Isolation

For the first 2 weeks, I wasn’t able to drive (because I couldn’t stretch my arm up to the steering wheel.) Though I did have a few outings, and regular walks around the neighbourhood, I felt isolated at home. I rested a lot and watched movies. On the second and third surgeries, this was easier to bear since I knew it would only last for a couple of weeks.

Other Complications I Didn’t Get

Before surgery, my surgeon warned me of other possible complications. They are:

Infection

Signs of an infection include fever, chills, and sweats. Also look for redness around the incision. It is normal to have a small amount of drainage from the incision in the first day or two following surgery. But if this persists, or if you see pus draining from the wound, contact your doctor immediately. Infection can require antibiotic treatment with pills or by injection. Rarely, surgery is necessary.

Nerve Damage

A possible complication involves injury to nerves around the shoulder. This usually goes away in two days to six weeks (this occurs in less than 1% of patients). Permanent injury that results in diminished use, function or feeling in the extremity can occur but is exceedingly rare.

Frozen Shoulder

Frozen shoulder (adhesive capsulitis) is when the shoulder is painful and loses motion because of inflammation. After shoulder surgery, the shoulder pain may prevent you from moving your arm. The lack of movement leads to stiffness and then even less motion. Over time, you become unable to perform activities such as reaching over your head or behind you. See the section entitled “Exercises After Surgery But Before You Start Going to the Physio” for safe movements you can do to avoid getting frozen shoulder.

Scar Tissue

Scar tissue can develop around the surgical site, which can interfere with your ability to move the shoulder joint normally. Physiotherapy after having arthroscopic shoulder surgery will limit the development of scar tissue.

Pain Syndrome

"Complex Regional Pain Syndrome" (CRPS) is not well understood. It can sometimes occur after surgery or injury.

Second Arthroscopic Shoulder Surgery - Excision of Calcium and Rotator Cuff Repair

2011-05-09T17:33:00.000-07:00

This arthroscopic surgery was undertaken to finish the job that was started with my first surgery, the shoulder decompression. Whereas the first surgery gave me some relief from the shoulder impingement, there was some pain remaining. Dr. Kokan, who performed the first surgery, felt that the surgery was successful. “While there is still some residual discomfort, her life is certainly much better than what it was before.” I wasn’t happy with this analysis and looked for an orthopaedic surgeon who specializes in shoulders. My GP and my physio both recommended that I see Dr. Leith, which I did. He believed that the calcium that was still in my shoulder under the tendon was the cause of my pain. So he performed my 2^nd surgery to remove the calcium by making a small slit in the tendon and pushing it out. Then he put a suture into the tendon to close it. The latter is called a “rotator cuff repair”. (Rotator cuff repairs may be much more elaborate, depending on the size and location of the tear.)

Differences from the First Surgeries

The differences between the 2 surgeries stem from the rotator cuff repair. From the time I awoke in the Recovery Room, I was made aware that I would have to take it easy on my shoulder this time. The repair in the tendon makes it weak until it is healed. Some differences in my activities were:

restricted movement until 4 to 6 weeks – e.g., moving elbow away from my side, lifting
wore sling for 3 weeks at home, 6 weeks when out of the house (vs. 10 days last time)
could type with both hands, wash the dishes, shower by myself at 3 weeks (vs. 8 days last time)
could drive at 4 weeks (vs. 2 weeks last time)
I took more medication, and for a longer duration

Cryotherapy Unit

Dr. Leith directed me to buy a “cryotherapy unit” for my rehab. (It was covered under my extended medical insurance.) This device (ironically, it is from Iceland) provides constant cooling by circulating ice water through a pad on the shoulder. This reduces inflammation, pain and the amount of medication needed. For the first 4 days after surgery, I wore the cryo cuff almost all the time. Thereafter, I wore it when sleeping or resting for 2 weeks; then only after exercising until 4 weeks.

Tips on using the unit:

wet the hose on the shoulder pad before attaching to the hose on the unit. This makes connecting the hoses easier.
instead of using ice cubes to fill the reservoir, you can make small blocks of ice by using a plastic margarine or other container. Two blocks in 2 inches of water will last several hours.

Strapping on the shoulder pad:

position the pad with the hose running down the outside of the arm
there are 3 white straps with velcro - use the shortest around the bicep; the middle length from the front of the shoulder under the arm pit to the back of the shoulder; and the longest strap from the shoulder across the chest, under the other arm and around the back to the back of the shoulder.
play around with the straps until the shoulder pad rests smoothly on your shoulder.

Video of Excision of Calcium

2011-05-09T17:10:00.001-07:00

Here's the video of the calcium being removed from my shoulder. The biggest chunk comes out at 2:16, after he has enlarged the slit. It made me so happy to see so much calcium being removed!

http://www.youtube.com/watch?v=zyI6UlTvAMQ

Summary

2011-05-09T17:08:00.000-07:00

I wish I knew all of this before I began this journey more than 2 years ago. (These are just my opinions, of course.)

Things I Learned About Shoulders and Conservative Approaches to Shoulder Pain

specialists don't agree about this (and my physio has flip flopped on the answer) but calcium in your joint hurts! Until it is removed, you will continue to have pain.
ice applied to the shoulder is very effective at relieving short-term pain, particularly after exercising.
it is a good idea to warm up your shoulder by doing some stretches before doing some heavy exercise such as mowing the lawn.
if physiotherapy isn’t solving the problem, get an x-ray. Then you can discuss options with your GP.
cortisone shots don’t work (for my problem, anyway)
needling only works if the calcium is recent
conservative approaches take a long time
specialists don’t agree about whether radial shock wave therapy works

Things I Learned About Orthopaedic Surgeons and Surgery

as soon as you think you may need surgery, get on a waiting list
the publicized waiting lists (e.g., http://www.health.gov.bc.ca/swt/) start after consultation with the surgeon
consultation waiting lists ranged from 7 months to 2 years. Surgical waiting lists after consultation ranged from 4 months to a year.
you can jump onto a surgical waiting list by paying privately for a consultation
I decided that experience is an important criterion in choosing an orthopaedic surgeon
see the post “Do as much as you can as soon as you can” re when you can do what after surgery

Shoulder Pain and Surgery – A Patient’s Perspective

Shoulder Pain Two Years Later

Natural Healing of the Shoulder

Chronic Complex Pain Doctor

Headaches

Neck Pain

Shoulder Pain

Mental Health

Thanks

Chronic Pain

Update on Cortisone Injections

Exercising the Shoulder

Chronic, Complex Pain

Shoulder Pain One Year Later

Steps Taken Since Surgery

Physiotherapy and Exercise

Cortisone Injections

Psychologist

Current Situation

Comments on This Blog

Top 5 Posts:

Shoulder Pain After Surgery

How Many Shoulder Surgeries?

Information on Specific Practitioners

Bi-Lateral Shoulder Pain – Both Shoulders at Once

Which Shoulder To Have Surgery On First?

Rehab When One Shoulder Has Not Had Surgery Yet

How Soon Should the Next Surgery Be?

Rehab When One Shoulder Has Not Finished Healing Yet

Summary

Calcific Tendinopathy Revisited

The basics:

Treatment:

The Roller Coaster Ride

Left Shoulder Journey Through Pain and 2 Surgeries

Latest Surgery

The Journey for the Left Shoulder

A Few New Things I Learned About Orthopaedic Surgery

Introduction

Timeline

The Normal Timeline - Conservative Approaches First

Physiotherapy

X-Rays

Anti-Inflammatory Medication

Consultation with the Physiotherapist

Cortisone Injection (aka Corticosteroid Injection)

Ultrasound

Needling

Other Conservative Approaches that I Didn’t Try

Radial Shock Wave Therapy

Prolotherapy

Platelet-Rich Plasma Therapy

Shoulder Pain

Impingement Syndrome

Calcific Tendinopathy (aka Calcific Tendinitis)

Imaging of the Shoulder

X-Rays

Ultrasound

MRI

Waiting Lists and the Private Health Care System

Waiting Lists for Orthopaedic Surgeons

Caveats About Waiting Lists

Private Health Care

Private Health System - Consultation

Private Health System - Surgery

Which Surgeon?

Dr. Peter Kokan

Dr. Danny Goel

Dr. Jordan Leith

Arthroscopic Shoulder Surgery - Shoulder Decompression

Pre-Op

Day of the Surgery

General Anaesthetic

The Surgery Itself

Sling and Dressing

Follow-up Visit(s) with Orthopaedic Surgeon

Timeline After Surgery

First Day

The Sling

Sleeping With a Sling