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Principles of Non-Operative Treatment

While there are some shoulder and elbow conditions that warrant immediate surgical treatment, such as displaced broken bones within the joint, the vast majority of shoulder and elbow injuries can be successfully treated non-operatively. There are four basic principles of non-operative treatment:

ACTIVITY MODIFICATION: “ACTIVE REST”

Simply put, activity modification means avoiding those activities that exacerbate pain, which is only common sense. For example, if your shoulder hurts when lifting weights overhead, no need to stop going to the gym, simply avoid those exercises that are painful and do strengthening exercises below shoulder level. The program is called “active rest.”

Pain is your body’s signal indicating damage of tissue and should not be ignored. Avoiding painful activities gives your body an environment that promotes the healing process which our bodies do continually and naturally. Given the opportunity, the body wants to and will heal injured parts. Non-operative (and surgical) treatment enhances the body’s natural tendency to heal.

MEDICATION

NSAID and Tylenol: If your shoulder or elbow hurts even at rest or during activities that you need to do for everyday life such as washing and dressing, then take medications to decrease pain. Nonsteroidal anti-inflammatory drugs (NSAID) and Tylenol are the mainstay medications for musculoskeletal pain. These medications do not “heal” injured tissues, your body’s inherent repair mechanisms do that, but they do allow you to perform everyday activities more comfortably.

Which NSAID to use is debatable and depends on individual choice. If there were one best drug, there wouldn’t be dozens on the market! While some NSAID’s are designed to have less gastrointestinal side effects, all NSAIDs are basically derivatives of aspirin which, for many patients, is also very effective. Use the NSAID’s (or Tylenol) that works best for you.

Cortisone: Some conditions, such as shoulder bursitis, are helped by other medications that decrease inflammation. The principal medication in this class is cortisone. In general, I recommend cortisone injections only after an initial period of rest, activity modification, and anti-inflammatory medications orally. I limit cortisone injections to no more than two or three injections in the same site no more frequently than every three months because cortisone can weaken tendons and ligament if administered excessively ( no one really knows how much is “too” much cortisone).

Ortho Biologics: In recent years, there is great interest in the role of another class of medications referred to as Ortho Biologics, such as Platelet Rich Plasma (PRP), Stem Cell Therapy, and Viscosupplementation. While there is great promise and enthusiasm for these new treatments based on laboratory studies, consistent and convincing success in the clinical setting has been elusive. Promotion of such treatment has been placed more on personal testimonials rather than objective and reliable scientific studies. For this reason, I do not advocate these treatments routinely. However, I do recommend that specialized centers, dedicated to the best clinical research, should study these medications and promote clinical trials to better understand which of these new treatments are effective and when they should be used.

EXERCISES

REHABILITATION

After giving your body the time and environment to heal (i.e., Activity Modification!), the next most important treatment for shoulder and elbow injuries is rehabilitation exercises. Such exercises are specific to the injured region and designed to increase both flexibility and strength. A physical therapist is an expert who instructs and assists you to perform these rehabilitation exercises correctly and the therapist can offer great value to the recovery process. However, one need not go to a physical therapist to do one’s “rehab exercises.” This exercise program can be performed anywhere, and the important point is that you perform the correct exercises consistently following instruction by either a physical therapist or your treating physician.

“NO PAIN, NO GAIN”

Pain is a sign of injury and damage to the body and should always be avoided in the course of an exercise program. However, you do need to push yourself to a certain degree during exercises so the muscles and soft tissues are sufficiently stressed to improve flexibility and strength. Rehabilitation exercises should be “work, not torture.” Push yourself enough to benefit from the exercise (i.e. soreness indicating a good workout), but did not overdo it and cause pain that persists after your exercise or requires you to take pain medicine for comfort.

We all appreciate the difference between the soreness and fatigue of a good workout and the pain of an injury. Paraphrasing of a famous quotation from a former Supreme Court Justice, “it is hard to define pain, but you know what when you feel it.”

CLOSED CHAIN EXERCISES

These are shoulder exercises performed where the hand is connected to a stationary object which can be the floor (i. e. push up), wall, machines, cables, or both hands holding and lifting a weight. An “open chain” exercise is one where a weight is raised in the isolated hand, i.e. single hand dumbbell lift. Closed Chain Exercise performed below shoulder level is a safe method to strengthen muscles in positions that do not irritate and cause pain in the shoulder. Start at the lightest weight, perform 3 sets of 10 repetitions, and progress with increasing weight gradually at a pace that does not hurt.

RETURN TO ACTIVITY/SPORT

The last phase of non-operative treatment is a gradual return to more vigorous activity and sports after you regain normal range of motion and strength and can perform the rehabilitation exercises comfortably and without pain. I recommend to start sporting activities at 25% of your former, normal intensity level, which should be pain-free. Gradually increase the intensity of activity 5-10% with each subsequent exercise session, again provided that there is no pain, until full activity is regained. This process typically requires 6-8 weeks and requires considerable patience on your part.

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