[Music] good evening and welcome to doctors on call I'm Dr Mary Owen associate dean of Native American Health and director of the center for American Indian and minority Health at the University of Minnesota medical school I'm also a family physician for the Fondulac band of Lake Superior chipa and I'm your host for our program tonight on upper extremity shoulder neck and back problems the success of this program is very dependent on you the viewer so please call in your questions tonight or send them in ahead of time to our email address the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Matthew Davies a neurosurgeon with Orthopedic Associates of duth Dr Ryan Harden a family medicine physician with the Gateway Family Health Clinic in sandstone and faculty member at the medical school of duth Dr Anthony burls a neurosurgeon with Essentia Health our medical students answering the phones tonight are Gabe Graves from Esco min Minnesota Jamie Vine from Lester Prairie Minnesota and Sophie Wong from Springfield Missouri and now on to tonight's program on upper extremity shoulder neck and back problems welcome doctors thank you thank you it's good to be here we have one question ahead of time so um I'll ask that and then we don't have any others so we'll just wing it have some conversation okay I'm gonna ask you Dr Dr Harding my shoulders are becoming rounded and head bent forward it's difficult to straighten up are there exercises or physical therapy that can help I'm 75 so I think that that has this patient is asking questions about their posture and it's it's difficult to change your posture in the short term so for this person if they were having discomfort or pain I would probably recommend that they look at the way that they're carrying themselves throughout the day what their posture is looking like maybe uh where they're working if they had if they were sitting all day long if they had a desk where they could stand up um if if they're looking down at a monitor or down at their work all day long I would probably Elevate the monitor if I could so they're looking at eye level and I think that would help to give them better posture and um physical therapy might help as well just to make strengthen some of the muscles so that they don't have pain later on right yeah y now you and I as family doctors see a lot of folks for back pain I mean every time we turn around we're seeing another back pain probably one or two people a day day right so colleagues when are we when should we be thinking about referring people for back pain yeah so back back pain in of itself pretty a non-specific finding as you know you see it every day uh really when people are having difficulty walking or they're having a lot of lower extremity or upper extremity symptoms is when we start to get more concerned about there being a neurological problem okay Dr burls anything to add I agree with that you know pain I guess that remains refractory to conservative treatments that we usually use physical therapy and then more ADV advaned treatments like injections May warrant a visit uh or at least a consultation with us U and we're often pretty open to receiving a uh a message from our uh colleagues in primary care just inquiring if there's any other tests to look at things to things to ask about um because it's a very common problem and there are a number of things that can cause it Dr Davies what do you um end up seeing the most in your clinic or what do you um what do you end up having to operate for the most often so I do a pretty fair number of both cervical and lumbar spine problems so neck and back problems that have been Progressive usually uh degenerative problems so I'm in Artis arthritis is a big portion of it or what we call degenerative disc disease okay Dr Burl same I would say our practices are probably very similar um so yeah degenerative conditions of the cervical and lumbar spine uh we end up seeing a fair number of traumatic uh problems at at asentia uh involving both the thoracic and and uh cervical and Lumbar spines um and then we have oncologic problems um so metastatic tumors uh or primary tumors of the brain and spinal cord so that I I would say probably in that order uh the problems we see okay Dr Davies do I need to have surgery this is from William from Grand Rapids wants to know do I need to have surgery if I Tor my front shoulder ligament maybe Dr Harden probably be good question to defer to my orthopedia colleagues for Dr Harden or Dr Harden if somebody tore well I don't know what ligament that's referring to but generally when somebody has um pain in their shoulder there's a lot of things that can cause that uh it could either be from a tear commonly the rotator cuff or a biceps tendon tear um usually we can figure out if that if somebody has a tendonopathy which is just inflammation in a tendon or muscle in or a muscle clinically we by the question questions we ask in the physical exam that we do on the patient we can usually tell if they have a tear or if it's just a tendonopathy now if it's just a tendonopathy that will usually get better uh with conservative management exercises resting it avoiding certain movements but if somebody has a tear um and especially if they have weakness that's something that might need surgical intervention okay all right for any of you is overthe counter glucosamine help with btis probably Dr Harden again I don't think glucosamine is used to treat btis I would probably lean toward something that's going to be anti-inflammatory like a steroid injection or ibuprofen or nids for for btis usually glucosamine glucosamine sulfate about 1500 milligrams a day is typically used for the treatment of arthritis osteoarthritis okay great um but you mentioned a couple of other treatments and saids be non-steroidal anti-inflammatories like ibuprofen commonly used and then you talked about stero I think you mentioned steroid shots do either of you use steroids a lot before you go to surgery and back yeah I would say that's a that's a pretty common uh medication whether delivered through an injection or orally uh to try and take away inflammation in and around the nerves that where we're operating for the most part um and so that's a pretty common thing that we'll use if nothing else to temporize people's uh symptoms uh before we ultimately pursue surgery in many cases uh between 50 and 75% of the time that's all we need to do uh take away the inflammation and that's usually our goal I know we've talked about this before uh trying to treat everything without an operation if possible so so you're it sounds like you're saying you can use it one time occasionally use it only once well it and it all depends on the on the person's uh other medical issues use uh we can use several steroid injections uh we tend not to use more than one or two rounds of oral steroids unless it's there's a really compelling reason to use more and Dr burls and I were talking about this before um two different types of injections that we use steroid injections are more therapeutic designed to treat the problem with the anti-inflammatory effects and then we can also use what's called diagnostic injections either litican or an agent like that to help us pinpoint where people's problems are coming from and then what do you do and then if we can localize it to a specific nerve we can often treat that surgically okay great thank you a caller from Virginia Minnesota and I'll ask you Davies Dr Davies because you're sitting right next to me although you might defer this again to Dr Hardin are there any new treatments for old wornout shoulders I will also defer well I'm probably what the caller is referring to in terms of a warn out shoulder is uh degenerative arthritis and we all get it it's like when you drive your car around on the streets the tires eventually wear out when we use our joints toward our life the joints eventually wear out osteoarthritis um generally the progression of treatment for osteoarthritis is we start with certain physical exercises maybe a referral to a physical therapist if that is ineffective there's overthe counter pain medicines aaminin ibuprofen nids if that's not effective at controlling somebody's pain then we resort to steroid injections which I do in my clinic and peripheral joints um and you can sometimes patients will get 2 3 4 years of relief out of steroid injections but eventually if that joint is really worn out doesn't respond to steroid injections it's time for surgery joint replacement and how many times and this is for the back too how many times a year can you get a steroid injection how long are they expected to last I usually limit steroid injections to every 3 months at the most frequent there's certain situations you would do it more frequent than that but usually I tell patients every three months at the most Dr barl I see a nodding okay agreed okay are there any risks to um what are the risks there's risk to everything what are the risks to uh steroid injections so most common risk with injections is pain either pain locally at the site or following the trajectory of the nerve that was injected on very rare occasions you can get a puncture headache so you can get a spinal fluid leak associated with an injection um very uncommon but one of the risks well since you're answering questions I have a I think you you you neurosurgeons can appreciate this one I have a twang in my shoulder upper back region would chiropracty CH uh would a chiropractor help I guess you can answer the Chiropractic question but I also have more general questions yeah in terms of Chiropractic here I actually I very much appreciate our Chiropractic colleagues in the area I think a lot of them do very fine work and so chiropr practic manipulations are there's a wide range of what they do um frequently for the upper back and shoulder blade pathology they do really good in terms of the manipulation and taking the whole spine into consideration uh often with a variety of different treatment options that they have very successful thank you for that what I was getting at is that um when patients come into our office for um upper shoulder one of the things we look at look for is a spinal problem so the testing that comes with that but thank you for that answer all right how can I tell the difference from Hermantown how can I tell the difference between shoulder nerve impingement versus btis Dr Harden um well the difference between shoulder nerve impingement and btis both of them will cause pain when somebody elevates their arm above horizontal um usually nerve impingement will not respond to a steroid injection whereas btis will give you you'll get a really good response from a steroid shot from a steroid injection all right thank you for that um Dr burus from Dory from Proctor Minnesota wants to know how um she has significant cervical arthritis what ongoing practices can she do to help stop the progression and help her current syst symptoms that's a great question and and I mean the honest answer is there's not a lot of things we can do to to Halt that progression uh one easy thing to do is if you're smoking stop smoking that inflammation is terrible for for your whole body but especially for your spine um you know at regular exercises and stretching usually uh with the guidance of a physical therapist can be quite helpful to establish a good routine uh and and a good plan um and that's probably the best things we can do uh try to maintain a healthy weight and to stay active uh but unfortunately we don't have great ways at preventing that that progression okay thank you Dr Davies do Cy sciatic nerve issues cause numbness and tingling in the feet so yes they can uh numbness and tingling the feet is also commonly seen in diabetic neuropathy so people with long-standing diabetes one of the most frequent symptoms is stocking glove numbness so tips of fingers tips of toes and it can progress upwards but yes uh peripheral nerve compression stic nerve compression can mimic those symptoms anything to add Dr BR I I think that's well said okay all right shoulder doctor what is the future of shoulder replacement and what is the recovery time typically like well I'm not at orthopedic surgeon but the the results that we get in modern shoulder replacement which is also called shoulder AR arthroplasty are dramatic Improvement in shoulder pain and so as far as the future of joint replacement I think that when somebody has a shoulder replaced either a regular arthroplasy or reverse shoulder as they're called um they're going to be painfree most likely and I usually tell patients you're going to have 90% of your pain and gone after six weeks and then after three months they should be back to Baseline in terms of their activity level and abilities all right I have a question I'm not sure of but I'll ask the question I have a ritis and back issues how does a arachnoiditis affect treatment and or surgery for my back yeah that's a tricky one I think we would all struggle with that answer but I can try to give it a shot so ridad is is inflammation of the little nerve Roots inside of the spinal canal so at the very bottom of our spine we are little nerve bundles that we call the K aquina these small little nerve fibers float around in the cerebral spinal fluid arachnoiditis is essentially inflammation of the covering of the nerves inside the spinal canal notoriously a very challenging pain syndrome to treat there are a lot of different treatment options that options that exist out there but yes knowing that ahead of time will help dictate whether or not you are going to respond to some of the more traditional spine surgeries that we have to offer okay go ahead Dr Bros yeah I would say that that's a very difficult uh syndrome to live with uh just because it's so hard to treat and so hard to diagnose and I think any spine surgeon that you meet with will probably uh take that into consideration okay Dr bur we'll start with you on this one um I heard of an MRI recently showing dis bulging arthritis and Central canal stenosis in c34 uh 45 and 67 what are some options what are the things that the doctor might talk with them about well and it I guess it really all depends upon the symptoms that the patient's having the thing we worry about the most in the cervical spine is compression of the spinal cord and that can lead to very severe symptoms begins with really subtle things that you may not notice numbness in your fingertips loss of dexterity poor balance and can progress to weakness and paralysis if not treated in time but things like dis bulging are are pretty common on MRIs and I suspect that most of us on the panel probably have some on if we were to get MRIs so it really depends a on the symptoms and then B what the actual pictures look like um so some some basic options provided the symptoms aren't terrible would be physical therapy and uh and that same stretching and and excise routine we talked of earlier for more severe symptoms we might talk about surgeries both from the front and back of the neck and it really all depends on what the overall Anatomy looks like anything to add Dr Davies yeah I agree that's well summarized okay I think I find it particularly hard sometimes to um have patients understand that like you just said on the MRI that the findings aren't necessarily enough on their own that you can see odd go ahead and yeah i' I'd add that the uh the language used to interpret MRIs is highly variable and and really a spinal specialist is really the one that that that's going to help determine you know how to interpret that and so bulges herniations um dissocation we we see these words all the time but there's not a a uniformity in the in how to apply them thank you for that yeah I'd say that Dr burrow and I get the luxury of being able to sit patients down and do a lot of Education that's one of my favorite parts of my clinic business it's being able to take this complicated MRI report and then walk them through one space at a time showing exactly what that means that's fantastic yeah all right a caller from duth mid 60s fell last year and tore his rotator cuff he was required to do weeks and months of PT before he could do surgery why does this this is a great question why does this happen is it insurance does it a delay recovery versus immediate surgery that is a good question um sometimes people will irrespective of what their MRI shows if they have a rotator cuffed tear or just a rotator cuffed tendonopathy sometimes people will have recovery of their symptoms without surgery and surgeries have potential complications we like to avoid surgery if we can think of it in most cases as a last resort and uh this person might have fallen and they might have had that rotator cuff injury decades ago and then they just fell had some acute shoulder pain and they had a Imaging study that showed that they had a tear which wasn't at all related to the injury so it's something very commonly we will recommend a course of rehab before we resort to surgery this is pro this is what I like about this show is that we're able to kind of give the back talk and really um confirm what people have heard from their doctors that surgery is not risk-free and that we don't jump into it without thinking about hard about what it might do the you know the good versus um are we the overall good versus the harm so a caller from nope we did that one uh Dr Davies what are your thoughts on stem replacement oh well no for shoulder issues back to you Dr Ryan on stem replacement yeah stem cell replacement for shoulder issues I don't know anybody I to be honest in my practice I haven't referred a patient for stem cell therapy for shoulder issues um I think that might be on the horizon in my practice it's somewhat experimental I haven't haven't had any of my patients that have had had that therapy Dr Bros I saw you look interested I I'm very interested it's a very promising treatment I I don't know of any uh uh well-run trials that would show that it's been effective uh that's the hope is that we can find treatments uh that will affect both the skeletal and and uh axial uh bones to prevent this arthritis but we don't have it yet unfortunately okay nothing to add Dr Davies I agree with that okay promising but not there yet I'll let you answer this one then could stenosis in the vertebrae of a nerve to the arm cause tramor tremors uh let's see so if I can try to interpret that if you had spinal cord compression not necessarily the nerve bad enough your myopathy was bad enough which is what we call our spinal cord compression you can get a syndrome that looks like a Tremor okay um hyperlexia or increase reflexes can kind of mimic tremors so yes the short answer would be yes you could have that anything else to add agree with that one Denny from matoa asks I have a full I have a dull consistent ache in one side of my neck could this be a pinch to nerve Dr bro uh potentially uh more likely based on just the description might be muscular and it could be facetogenic the facets are sort of the knuckles that allow your neck to Bend forward and backward um and so like a lot of things we would treat that with a course of physical therapy stretching and flexibility exercises an evaluation with probably your primary care physician and possibly Imaging studies um but a lot of it would be based on the history and and some probing questions that we'd ask in person you know the kind of pain where it goes what makes it better all those things that we ask almost everybody we see which brings me to the next question very similarly having shoulder pain for a year what can I do without Insurance any home remedies exercise High repetition low impact exercise frequently uh wouldn't I wouldn't do any exercise that would generate pain don't overload the shoulder ibuprofen Tylenol and give it a little bit of time and if it doesn't then go see your doctor and consider of course of physical therapy maybe a steroid injection and we do have clinics that um there's one on the West End where you don't have to have insurance so you can go but uh Cara on the North show Shore had a frozen shoulder and one fro one of her shoulders was frozen she heard there's a greater chance of getting it on the other shoulder is there anything she can do to prevent another frozen shoulder well Frozen shoulders caused by diffuse inflammation in the in the joint capsule in the shoulder so um absolutely activity I would say swimming overhead activity that doesn't cause pain in the joint um and again High repetition low impact exercise like swimming you wouldn't want to do any significant weightlifting or something like that that might actually worsen it or cause trauma but and maintaining range of motion to prevent frozen shoulder is really important thank you Dr burrow what are the be from Sarah what are the best and worst things you can do for spinal Health starting Young And as you age well we we can easily start with the worst things that I think we can all think of a lot of things but um you know if obes puts a lot of strain and stress on your back and and causes your discs and and facets to wear out much more quickly uh similarly I mentioned before smoking makes makes things much worse just generally increasing that inflammation and then inactivity um and I think those are the three worst things you can do um so the three best things you can do are to be active be healthy don't smoke and try and maintain a healthy weight which is which is difficult um but there are a lot of options out there um and we see people all the time in from all of Life who work in manual labor or desk jobs who have similarly uh degenerated spines so I I would say live your life as you normally would try and maintain a healthy weight stay active and don't smoke it's interesting that you mentioned the con well construction like work the laborers um oftentimes I'll have patients who come in and think that um because they labor all day they're doing the exercise that they need to and yet we know from having seen so many patients that if you're not watching out for your back and doing other exercises as well and I would say it's I mean it's a great way to maintain strength but you want to balance it out with core strength and and also balance that with flexibility and so there are exercise programs the the spineex program um that's available through several Health Centers is is a very great way to to strengthen your core um and do so in a healthy Progressive Way okay um Dr Harding my son's left arm has has gone numb because of a back pack a very heavy backpack what's going on and how do I fix it that's a great question um so what's happening I think is the backpack's too heavy and the strap of the backpack is pushing on the bracho plexus which is a bundle of nerves that go from the neck into the arm um I I would say get a different backpack or sometimes you can get a backpack that wraps around the waist where the weight is distributed or or uh decrease the amount of weight in the backpack and if the usually with what's called Backpackers py is the name of that condition uh if the if the numbness and tingling is intermittent they're going to be fine but I would not put so much weight in the backpack and or put both arms up yeah instead of just one we see students do that a lot we don't have too long but I think we might get this one in from Lois can you explain the structure of the tpus and what injuries are the trapezius present with symptoms Etc so the trapezius is a muscle that goes from the shoulder to the back of the neck uh to the midback and injuries that will present with trapezius pain that's a the trapezius is a very common muscle to have a muscle spasm in so and usually when people have that they can reproduce the Pain by pushing on their trapezius which is right here and that's amenable to uh physical therapy and sets and sometimes muscle relaxers like cyclobenzaprine or flex ril and I think this is the time of year when we start to see it more people hunched over the driving driving get really bad trapezius pain all right um I think we might squeeze one more in I have mild spinal bifida and mild scoliosis when I bend down my right buttock and mid upper leg goes numb what is the cause they related to those things and short answer they could be um that would require additional Imaging typically we would want an MRI the low back that would ow us to look at the nerves a little bit more and understand the nature of your spine Abid and scoliosis okay anything else to add Dr buros No Perfect all right well thank you all for being here thank you I want to thank our panelists Dr Matthew Davies Dr Ryan Harden and Dr Anthony burough and our medical student volunteers Gabe Graves Jamie virgine and sopie Sophie Wong please join Peter nen Dr Peter N sorry about that next week for a program on ENT problems including s sleep apnea when his panel will include Dr Todd Freeman Dr Robert GRL and Dr Thomas Guston thank you for watching and good [Music] [Music] night [Music] that