Shoulder pain is a common complaint. In fact, I’d estimate that it is one of the most common complaints I see. In most cases, the diagnosis is rotator cuff (not “cup”) strain or tendinopathy. The good news is, most of the time, it’s non-operative. That means it likely won’t require surgery. It also does not require an MRI for the diagnosis, contrary to common belief.

First, let me review the anatomy in basic terms. The shoulder joint is a ball and socket joint. The socket is very shallow, which allows for the great range of motion we have in the shoulder. However, this makes the role of the rotator cuff critical. The rotator cuff is made up of four tendons, and these tendons stabilize the humeral head (top of the arm bone) in the shallow shoulder joint. When these tendons as a group are weak or not working properly, other structures become impinged, causing pain. I must also mention the scapular stabilizers (trapezius muscles, rhomboids, etc.) here. In addition to the rotator cuff, these muscles are critical for normal shoulder motion because the glenoid, or the “socket” part of the joint, is actually part of the scapula, or shoulder blade. Often times scapular motion suffers as a result of shoulder pain, but it also commonly contributes to the discomfort. Over time the muscles and tendons can become weak or imbalanced as a result of overuse or poor mechanics. This results in a tendinopathy, or prolonged injury to the tendons.

When evaluating shoulder pain, I assess range of motion and strength of the rotator cuff, in addition to some special testing. The history, physical exam, and x-rays often tell me what I need to know, without having to rely on advanced imaging. Many of my patients think they need an MRI to rule out a rotator cuff tear, and sadly, some physicians will order one automatically when they hear “shoulder pain.” Here’s the thing: the likelihood of a rotator cuff tear increases as we age. And like I said, the physical exam can tell us a lot. So if I see a 25 year old male with gradual onset of pain who demonstrates good range of motion and strength on exam, I am not suspicious for a full-thickness tear. However, if I see a 65 year old female with severe pain after a fall or other trauma, I am more suspicious for a tear, and I will order the MRI to evaluate.

The good news is, young to middle-aged folks respond very well to conservative treatment and rehab (which usually involves physical therapy). Re-training the rotator cuff muscles and tendons, in addition to the scapular stabilizers, is critical to the treatment plan. This isn’t something that gets better overnight, but it should improve with time as the shoulder mechanics improve.

The treatment of rotator cuff tears is not always so simple. Full-thickness tears are quite painful and will not heal on their own, requiring a surgical repair. However, many partial-thickness tears can be treated conservatively. While they won’t heal, per se, they will “quiet down” and become less painful over time. Unfortunately, there is no way to predict which partial-thickness tears will progress to full-thickness tears and which ones will become less troublesome.

Of course, there are exceptions to the rule, and I won’t belabor those points here. It would require another post to address injuries specific to throwing athletes, another to address instability in the shoulder, and another to address injuries of the acromioclavicular (AC) joint. So that’s it for now. When in doubt, see a sports medicine physician who understands common pathology in the shoulder and can make appropriate treatment recommendations based on your particular problem.

Accountability.
According to Merriam-Webster.com, the definition is this: the quality or state of being accountable. especially : an obligation or willingness to accept responsibility or to account for one’s actions.

I feel as though society completely lacks accountability these days. I believe this to be true in many aspects of life – financially, socially, morally, among others – but since I’ve been involved with health care for my entire adult life, this is what I’ll address today. In my opinion, many American adults do not hold themselves accountable for their own health and well being.

I first saw it in medical school. I didn’t understand why patients with peripheral vascular disease or diabetes simply wouldn’t at least try to quit smoking or walk a few times a week for exercise. “I can’t afford Chantix (smoking cessation medication),” they’d say. “Well it’s less than what you’re spending per week on cigarettes,” I’d say. “But my husband loves donuts, so I have to buy them,” they’d say. “Well, try to eat something else,” I’d say. You can see why it didn’t take long before I was banging my head against the wall. The worst part about it was spending so much time and effort on patient education and lifestyle modification, only for the next question to be, “Can’t I just take a pill for that?”

Fine, I thought. I just won’t go into primary care. Sports medicine is where it’s at! Everyone loves treating athletes. However, going into sports medicine is more like going into musculoskeletal medicine. A lot of people, not just athletes, have knee pain or shoulder pain. And some of those people come see me. As time goes on I’m starting to realize that a significant percentage of those patients want one of three things: an MRI, a cortisone injection, or pain medicine. Sometimes all three. Problem is, they don’t know why! “I think I need an MRI.” Really? Why’s that? “Well, I don’t know… my sister-in-law had shoulder pain and her doctor ordered an MRI.” Gee, thanks. They didn’t teach me that part about doing what everyone else is doing when I was in med school.

I also have a “friend” with recurrent abdominal pain, cause unknown despite multiple lab tests and imaging. “The doctors have no idea what’s going on,” she says with disgust. She has a long-standing, skeptical view of medicine and doctors. Despite the fact that I am, in fact, a doctor, she asked for my advice. Should she see another specialist or seek another diagnostic test? “Well, that depends – can you tell me what tests have already been done?” I asked. “Um, I think a CT scan, some labs, I’m not really sure.” Here’s an idea – why don’t you take charge of your health, be accountable for what’s going on with your body, then we’ll talk. The first step in diagnosis is to get a good history, which is the patient’s account of what’s going on. It’s difficult to establish a diagnosis without a good history.

I think the finest example of this lack of accountability was in a middle aged female I saw recently for knee pain. She had seen one of my colleagues 6 months prior, at which time conservative treatment was recommended for her, including weight loss, as she weighed in at 300 lbs. We worked her into the schedule because she was having such horrible pain. I soon discovered that she had seen another physician the previous day, who had given her a cortisone injection. She had no relief, hence, her visit with me. I also discovered that she had in fact gained weight over the last 6 months, and had not done any of the recommended exercises for at least 3 months. When asked about this, I was given every excuse in the book about why this was the case. I was also interrupted several times by her husband, who took a defensive stance on the weight loss subject. Let me assure the reader that I was in no way hurtful with this conversation, but matter-of-fact. There is evidence to support the recommendation of weight loss for knee health. I emphasized the simple fact that her knee would not feel any better if she did not lose the weight. The visit ended with her asking me to give her pain medication and… wait for it… a note for bedrest!!
Why is it that so many patients just want a quick fix? If your (insert body part here) hurts badly enough that you took time out of your day to seek your doctor’s advice, why can’t you take the time out of your day to do what your doctor recommends? Are your health and well-being not worth the effort? And if I recommend physical therapy instead of a surgical consult, why are you disappointed? I’m so confused by this. I kid you not, I’ve heard a patient speak these words: “Are you kidding?!? Just physical therapy? I just want back surgery!!” Can’t make this stuff up.

Don’t get me wrong, most of my patients are very compliant and pro-active when it comes to their health. It’s just that subset of patients who want the easy way out, no matter what the diagnosis is. I think that as a society, we need to learn to be accountable for what we do, financially, socially, and personally. My recommendation for patients is to keep track of everything – if you had a cortisone injection, remember when it was and why it was given. Keep a list of medications. Obtain a copy of any imaging (CT scans, MRIs, etc.) for your own records. I also (strongly) suggest following the recommendations that are given to you by your physician. For example, try the physical therapy – just because it doesn’t relieve your pain overnight doesn’t mean it’s not worthwhile. You might find that when you participate in your own health care, it works out in your favor. After all, if you don’t take care of yourself, why should you expect someone else to do so?

As I mentioned in a previous post, I do not advocate for any one diet or another. I do enjoy most things in moderation, and I’m not a big fan of depriving yourself of things you really enjoy. However, I have recently been asked about the Mediterranean diet, and while I don’t adhere to it strictly, it has a good basis. I’ll explain why.

First of all, it’s not so much a diet as it is a pattern. It’s about choosing low-risk fats over high-risk fats, and it emphasizes exercise. There is also emphasis on foods that are rich in antioxidants – think anti-aging, anti-inflammatory, super troopers that have even been suggested to prevent brain aging. The Mediterranean diet has been linked with a significant reduction of mortality due to cardiovascular events, stroke, and cancer, as well as reduction in the incidence of diabetes, high cholesterol, metabolic syndrome, Alzheimer’s disease, and Parkinson’s disease.  Here are the highlights:

Fish – cardioprotective due to omega-3 fatty acids, and it’s a good source of protein. Red meats and certain dairy products are high in saturated fat, which has been linked to cardiovascular disease, especially in smokers.

Olives and olive oil – rich in antioxidants and monounsaturated or low-risk fats, as opposed to butter or margarine

Vegetables and fruits  – high in fiber and rich in antioxidants

Spices/herbs  – instead of salt, which increases risk of high blood pressure and stomach cancer

Nuts , seeds, whole grains – high in protein, fiber, and low-risk fats

As you can see, this does not include processed foods and carbohydrates, so it is not your typical American diet. I think what the diet doesn’t include is just as important as what it does include. You might be saying, “If I adopt this type of dietary plan, it’s going to cost me.” This is true.  But think about it this way – you could eat cheaper, processed foods full of carbs, fats and sugars NOW and then pay more for medications, procedures, and hospital stays LATER. Am I being dramatic? Maybe. But if your health isn’t worth the investment, then what is?