For almost eight years, Mr Ang, 69, ignored the pain in both his shoulders. He continued to travel overseas frequently and enjoyed a weekly game of golf.
Then the pain in his right shoulder got worse. He had trouble with day-to-day activities and found it difficult to raise his right arm above his head. Sleep became fragmented from the pain.
When Mr Ang consulted me for the pain last year, he could feel a "grating" sensation when he moved his shoulder.
Results of X-ray scans revealed severe degenerative wear of his right shoulder, and he decided to have surgery to replace the damaged joint with an implant.
OUR MOST MOBILE JOINT
We use our arms and hands constantly throughout the day, even when we are sitting down to read, eat or reach for our phone.
The shoulder is the most mobile joint in the body, allowing for movements in six directions or a combination of these. It is a ball-and-socket joint-so named because the end of the arm bone is shaped like a ball, which fits into the end of the shoulder blade, which is shaped like a shallow socket, or cup. Soft tissue structures such as the labrum, capsule and ligaments stabilise the joint, while muscles such as the rotator cuff help to move it.
In the elderly, joint degeneration can lead to the wearing of bones and cartilage. This can lead to pain, stiffness and disability for some people. These patients are usually given oral or topical relief and anti-inflammatory medication, or an injection of steroids and pain relief medicine into the joint, in addition to physiotherapy.
They will also have to make changes to their routines, such as reducing strenuous upper limb and overhead activities. Surgery is often the last resort. It would entail a total shoulder replacement, where both the diseased sides of the ball-and-socket joint are replaced with metal and plastic bearing surfaces.
Today, newer surgical techniques and implant designs allow better outcomes to be achieved through less invasive surgical methods and less blood loss. This helps the patient recover faster, which also means a shorter hospital stay.
In the last two years, the National University Hospital has seen a four-fold increase in the number of total shoulder replacements.
Our average patient today is 72 years old and is hospitalised for two to four days after the operation, compared with an average of five to seven days previously.
Mr Ang underwent a total shoulder replacement six months ago and was discharged on the second day. Two months after the surgery, he had gained a full, symmetrical range of movement in the shoulder, and no longer had any niggling pain. He is now considering getting his other shoulder treated and is looking forward to returning to his golf game.
Studies have shown that following a shoulder replacement, golfers can safely return to the sport after eight to nine months and can even enjoy improved driving distances and lower handicaps. But not everyone can have a total shoulder replacement.
SHOULDER REPLACEMENT OPTIONS
Another patient, Madam Bong, 78, injured her right shoulder while carrying heavy groceries.
She had felt a "pop" in her shoulder, followed by sharp pain.
Bruising and swelling occurred at her shoulder, which later went away. However, the pain persisted and disrupted her sleep.
It was only six months after the injury that Madam Bong consulted me. By then, she could raise her right arm only 50 degrees, compared with 140 degrees on her left side. A magnetic resonance imaging scan confirmed a massive irreparable tear of her rotator cuff muscles.
These muscles had also degenerated and had become fatty over time. This had caused the ball portion of her joint to move out of position from its socket, resulting in abnormal wear of both joint surfaces.
However, a total shoulder replacement was ruled out because it required one's rotator cuff to be healthy. Instead, she underwent a procedure called reverse total shoulder replacement.
This is where the ball-and-socket components are switched to the opposite sides. This allows other bigger muscles around the shoulder to compensate and power the shoulder joint.
Six months after the surgery, Madam Bong had regained all the motion in her right shoulder. Most importantly, she is now pain-free and able to sleep well again.
While not everyone can recover as well as Mr Ang and Madam Bong after a shoulder operation, this is the ideal which doctors strive for.
That said, a shoulder replacement is a major operation.
It comes with the same risks as any major surgery. These include infection, scarring and injury to the nearby structures, as well as risks associated with the use of anaesthesia.
Joint replacements also carry the risk of implant dislocation and wearing or loosening of the implant components over time. The bones adjacent to the implants could potentially break while the implants are being inserted, or if the patient were to fall and hit the shoulder after the operation.
The decision to have a shoulder replacement should be one you make with your doctor, after careful discussion of your situation, including the conservative option of managing the pain with medication, physical therapy and lifestyle changes.
Regardless of age, anyone can enjoy a good quality of life through proper evaluation and treatment of his or her shoulder condition.
• Assistant Professor Ruben Manohara is a consultant at the department of orthopaedic surgery, National University Hospital. He sub-specialises in shoulder and elbow surgery as well as orthopaedic trauma.
Source: The Straits Times © Singapore Press Holdings Limited. Reproduced with permission.
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