SHOULDER SURGERY AND REHABILITATION
All parts of Jacqueline's story are anecdotal and not meant to be taken as medical advice. See a doctor if you have any questions or concerns about your health. Click here to read Dr. Magovern’s thoughts on Jacqueline’s surgery and recovery.
What physical activities do you love to do?
There's so much I've done and more that I want to do. I am retired now and when I retired, I never stopped. I roller-skated and did all kinds of activities and classes. Anything anyone told me about I would do…crafts, sewing, or going to Broadway plays. I love line dancing and swimming. I've travelled extensively, to South Africa, Europe, Hong Kong, Israel, Mexico, Alaska, and Hawaii. For exercise lately I love to do water aerobics, but I haven't been able to travel and do any activities for a while. I had to gradually cut things out because I couldn't handle the pain in my shoulder anymore.
What happened to your shoulder?
It's mostly age because I didn't fall or anything. About eight or nine years ago doctors told me that my cartilage was deteriorating. I still felt pretty good doing all kinds of exercise, so I knew I didn't need surgery yet. The pain got worse, though, and it would wake me up in the middle of the night. I started taking Glucosamine and MSM to help, but my doctor told me it was making my cholesterol go up and I had to stop. Then I was back in pain all over again. I was starting to really lose my cartilage and I decided to change doctors. My new doctor started connecting me to different specialists, which is how I met Dr. Magovern.
What did Dr. Magovern do?
He discovered after taking MRI's and thoroughly testing and examining me that my right shoulder joint needed shoulder replacement surgery because it was bone-on-bone. That made me realize I had to do something about it right away. During one of my consultations with Dr. Magovern I told him that I felt I was just a bit too old for surgery, and he said, "You're never too old!" He talked about how I was in good health and that my age didn't mean that I couldn't have surgery. I also have a 42- year-old daughter who knows so much about this new technical stuff and that medicine isn't like it used to be when I was growing up. My daughter said, "Mom, no one goes around in pain like that. Doctors have all new things and you don't have to worry." I also talked to other women who have had more surgeries than I would ever think to have—on their hips and their knees and whatever—and they were so happy they'd done it. I said, "Wow, what am I waiting for?" I decided to have the surgery and ever since I haven't regretted it.
I had some pain one morning in the hospital after surgery because I accidentally didn't take my pain medicine. You need that right after surgery! Other than that I haven't had one bad day or night since. I'm already going to therapy and the therapists are just awesome. They are really, really good at working with me and I am able to do all kinds of things now. I can give people high fives and so forth.
Once your shoulder is recovered, do you think you'll start being really active again?
Yes, I'm looking forward to picking up water aerobics again! I feel wonderful but I have to wait until Dr. Magovern says it's okay to do it. I'm excited. I don't know why it took me so long to have surgery in the first place.
When Dr. Magovern talked to you about having surgery, had you tried any other therapies?
I had a Cortisone shot and it did nothing but leave a great big mark on my arm. It didn't work at all. I also had about 12 weeks of therapy some years ago but it just didn't do any good. That was when I started taking the Glucosamine.
What did you like best about Dr. Magovern when you met him?
It just seemed like our personalities must have clicked. I loved his bedside manner. He is a warm person and was concerned about me. He explained his credentials to me and how he specialized in upper extremities and especially the shoulder, and how he had taken classes for extra credit so he could learn more about it. He even teaches and oversees other doctors. That was very impressive. I could tell he knew what was going on in his field.
I told him I was very scared, and he was really nice and I felt like he was a friend. He told me the truth when I asked him how late I could change my mind. He said if I got on the table and changed my mind he would just stop! So his personality was what I liked about him. Even when I was in the hospital he was very attentive. He came just about every day. I know he had a busy schedule, but I'd look up and he'd pop in the door and ask how my shoulder was and how I was doing.
How has your rehabilitation process gone?
When I came home, my husband was helpful with fixing meals and helping me. In about three weeks or less I was able to get up and start doing things. I never really liked to sit down, but I was very careful not to move my arm. It was in a sling and I wasn't allowed to pick up anything heavy. I really followed Dr. Magovern's instructions. I started physical therapy and it has been good ever since.
Are you okay with how your incisions from the surgery look?
They are disappearing now, just fading away. Every week they're looking better. I asked Dr. Magovern to please make the incisions so that I can wear sleeveless clothes! I didn't want the incisions to show. So he did it well, and now when I put on a sleeveless blouse it looks pretty good.
What advice would you give people who are in pain like you were but are afraid of surgery?
I would tell them the truth about how scared I was, but if they want to go for it, it would be to their advantage. If there was any way I could refer others to a doctor, I would refer them to Dr. Magovern.
Why would you recommend him to other people?
Because he is a very warm, caring person and his bedside manner is superb. I love the way he answers questions. He seems like he's not only your doctor but someone you've known for a while and who understands you. He meets your needs if at all possible.
Are you glad you followed his recovery instructions so closely?
Yes. I decided that he knew best and kept my arm immobile and in my sling for as long as he told me to. I've heard people say many times that they've had surgery and wouldn't do it again because it didn't work. I wondered what happened, but having been through it myself I suspect what might have happened is that they didn't do what they were supposed to do. Sometimes people think that when they have surgery, that's the end of the matter. But you have to follow through because the healing process is the most important. I can't imagine having a better doctor than Dr. Magovern, but we were a team. I did my part, too.
JACQUELINE’S SHOULDER SURGERY
Brian Magovern, MD is an orthopedic surgeon specializing in the shoulder and elbow areas, and in trauma surgery. He is board certified.
Here Dr. Magovern discusses the shoulder replacement surgery of Jacqueline, one of his patients. Click here to read Jacqueline's interview.
Why did you become an orthopedic surgeon?
I wasn't going to be a doctor at all. In college I happened to take some basic medicine classes and realized it was perfect for me. I loved it. I felt like I was a people person, like medicine might be great. I always liked using my hands, doing projects, and building and construction, so orthopedics seemed to fit in perfectly with that.
Why are you passionate about it?
I probably like it more now than I ever have, and I love it more each year. Most of all I love seeing patients and their family members and building a sense of community and relationships. The field itself is very dynamic. Being able to bring new technology and improved techniques to my patients is so rewarding. The patients get better faster and have fewer complications, so it's a win-win. I've been practicing for a while now, and I've honed a lot of skills and am very efficient. It's really nice to create treatment plans and go into surgeries with that confidence.
You practice at both TOSMG and Harbor-UCLA Medical Center. What do you do at Harbor-UCLA?
Part of each week I work in the operating room with residents that are training to be doctors. I supervise them during surgeries, primarily treating traumatic shoulder and elbow injuries. Afterwards I see the patients for follow-up visits alongside the residents so they can learn the whole process of being a doctor. I also give teaching lectures at Harbor-UCLA. The rest of the week I see patients here at TOSMG and perform surgeries for them when necessary.
How does your personal background in sports and other interests affect how you relate to your patients?
I see patients of all ages, activity levels, injuries, and with different levels of health. I can easily relate to my younger patients who do sports because I've had some of the injuries they have and played some of the sports they play. I enjoy taking care of my older patients just as much because I see how effective the treatments and surgeries are for them. I know what they're going through. I can relate to them really well because I see how beneficial it is for them to get back to the things they need and love to do.
What kind of outcomes should patients expect after treatment or surgery?
Every patient is different, but in general for older patients it's often possible to get back to doing 100% of what they were doing before they had shoulder or elbow problems. It's very possible because that age group has a relatively lower demand lifestyle and often don't participate in extreme sports activities. Younger athletes can also have high expectations to get back to where they were, but it can sometimes take longer to get a top-performing athlete back to their peak high-performance level after a surgery. They should maintain that optimistic attitude but remember that it sometimes can require extra commitment to get through the recovery period to achieve what they consider "normal."
What did you think when you first examined Jacqueline?
When I first met her she was absolutely miserable, and I remember looking at her x-ray and just being shocked at how bad it looked. I'm always amazed at how long some people wait and she had really, really toughed it out. Her shoulder looked awful and painful. The cartilage was long gone decades before I saw her.
Did you know right away what she needed?
I knew that if she had exhausted all of the conservative options, such as therapy and injections, supplements, and gentle physical activity like stretching, that she would be a very good shoulder replacement candidate. She had done all of those things and was sent to me by a referring physician who knew I'd had extensive training in shoulder issues and would be able to treat such an extreme case of cartilage deterioration.
What was unique about Jacqueline's case?
Some people have some minor wear and tear that causes a lot of pain, while others have horrendous looking arthritis on an x-ray but they tolerate the pain or modify their activities. The severity of Jacqueline's arthritis was beyond even what I usually see. Her x-rays showed very, very advanced arthritis as well as a lot of bone spurring and thinning of her rotator cuff. I was concerned that not just her joint needed replacing but that the tendons around it also might be a problem.
How did you handle all of that? Did you have to wait for surgery to fully evaluate her?
The studies and MRI and CT scans that I did ahead of time gave me an idea of what to expect, but I knew that I would have to make a decision in the operating room. I actually had three different implants available during her surgery, depending on what I found. Luckily her rotator cuff was okay, and I was able to put a normal total shoulder replacement in.
Why, even with an extremely advanced case of arthritis, is Jacqueline such a success story?
She is such a great success story because her surgery went very smoothly and I was able to preserve her rotator cuff and put in a total shoulder replacement. She was great in therapy and did everything I instructed her to do after surgery. Her result is what I expect from a shoulder replacement. It's a great operation. It's really good for relieving pain and it secondarily restores a lot of motion when patients have a really stiff joint. When a smooth surgery is followed by patients participating and complying with their recovery plans, I expect great results.
Do most patients comply well?
In the field in general it's hit or miss. I take extra care to evaluate my patients' lifestyles, health histories, and expectations so that I'm only recommending surgery for those who are really going to have a better life afterwards. No two patients are identical, and it's an art putting together a treatment plan for each one. I don't take that lightly and my patients appreciate my attitude.
What did Jacqueline's case have in common with other patients you have treated?
It's common, like in Jacqueline's case, for a patient's shoulder to be very stiff before surgery, a condition that makes the regaining of motion more difficult. To get an ultimate outcome it involves a combination of my surgical expertise, performing releases of all of those tight tissues to get that motion back, and the patient following through with recovery instructions and physical therapy.
What would you say to a patient in a similar situation as Jacqueline's?
The vast, vast majority of patients can expect excellent pain relief and improvements in their motion. That doesn't mean I jump to surgery with anyone, though. I go back to the basics with all my patients, making sure they've tried everything they're comfortable with before surgery. Some patients do end up having surgery, but when they do, they're ready mentally because they've gone through the proper process.
Do most patients come to see you long after they should have?
Everyone has a thermometer inside that tells how soon to see the doctor when something is wrong. Although there are exceptions, most people come in about the right time, where they can be diagnosed and helped back to excellent function.
What can you do for people who come in earlier?
I don't discourage patients who come in with less severe symptoms. Often they do very well with anti-inflammatory medication and minor activity modification. If after two or three weeks there's been no improvement, then we talk about the next steps. Surgery is still a long way off at that point.
Roughly what percentage of your patients do you operate on?
Probably fewer than 10%. Most people definitely do well with non-surgical options.
For the patients who do need surgery, what do they have in common?
Their disease process is bad enough that it's not healing on its own and with conservative treatments. A few examples would be a rotator cuff tear, a dislocated shoulder, or shoulder arthritis. Again, those patients also tend to do better with surgery because they have exhausted all the other options.
What kind of pain should people not ignore?
See a doctor for any pain that keeps getting worse. Don't wait to be seen if you have an accident that results in pain. Have the injury diagnosed so it can be treated correctly right away. Sometimes pain at night can signal a problem. I've seen cases with night pain where something more systemic than an orthopedic issue was going on, like a tumor or something else that's serious. Don't ignore neurologic issues, like a weakness. If you can't lift your arm or leg properly or you have numbness and tingling, see a doctor right away. Any pain that's associated with constitutional symptoms, such as weight loss, fevers, chills, or general ill health should be looked at. If you have pain that's keeping you from doing activities or work that you're really passionate about, that needs to be addressed. You don't want that secondary depression to kick in because you are now unable to do the things you love. It just adds another layer of negative circumstances that you could be getting treated for.
When you see a patient who seems depressed, how do you address that?
I'm not a psychologist, so I don't actually diagnose depression. I do understand the emotional frustration of feeling helpless or stuck, so I'm able to help most of my patients with a few suggestions. Just talking with them and hearing about what's been going on helps a lot of them. Others start to feel better when we begin treatment and see improvement. I also refer most patients to a website where they can read about other people who have the same problems. That way they know that other people are going through the same things, and they can get tips on how to cope. It helps them feel positive that there are all kinds of treatment options to help them feel better again. Just realizing they're not alone is a huge help in itself.
Should people see an orthopedic surgeon before seeing a physical therapist?
Absolutely. Patients need a prescription from their orthopedic doctor to give to the physical therapist. That prescription directs the therapist to treat the issue the doctor has diagnosed, usually with the help of an x-ray, MRI scan, physical examination, or all three. There are certain, more serious conditions, that an orthopedic surgeon can rule out that a physical therapist may not be looking for. I'm a medical doctor, so I know the cardiac system, the kidneys, cancer, tumors, and other things about the body. Physical therapists are trained almost solely in the musculoskeletal system, so they cannot provide everything that's necessary for an initial patient evaluation.
My patients' recoveries wouldn't be complete without the expertise of physical therapists, though. Physical therapists spend a lot of time with patients and they also sometimes pick up on subtle findings that an orthopedic surgeon may not, so I stay in close communication to make sure the treatment is going along as expected. I listen to the physical therapists and am more than open to any thoughts they have about the treatment or progress of the patient.
What would you say to people that are scared of surgery?
If a patient has been properly evaluated by their doctor, has tried everything short of it, and medically is a good candidate, then there aren't many logical reasons to be scared of surgery. If there are any outstanding questions or issues that make a patient scared or nervous, then I would encourage them to get other opinions until they're satisfied with their options.
How do you explain the risks of surgery to your patients?
I'm very realistic and have a frank discussion with each of my patients who are considering surgery. There are risks and it would be silly to say there is no chance that there is going to be a problem, but it's really incredibly rare. My track record is also excellent. I do hundreds of surgeries every year without any major problems and very, very few minor ones. Once people know all this they feel more secure about choosing me as their surgeon.
You've had patients that have followed their rehabilitation to the letter and those that haven't. What's the difference in their outcomes?
There's no question that there's a huge direct correlation with postoperative compliance and a patient's recovery. By far the average patient that follows their prescribed protocols has a much better outcome than the patient who doesn't.
Every recovery is different. What different "normals" have you seen?
I take care of two different patient populations that can be divided into 1) those who have traumatic injuries and fractures, and 2) those who have age-related wear and tear. They have two entirely different recoveries and it is amazing to see.
I'll compare a shoulder fracture to a shoulder replacement. A shoulder fracture often happens to someone in perfectly normal health who then has an accident and is suddenly totally disabled. I'll operate and fix the patient's shoulder and have them begin rehabilitation. This type of patient usually gets back 95% or more of function. If they do end up at 95%, which is really, really good from a medical perspective, they are 5% less than they were before they got injured. Sometimes not getting that 5% back is mentally tough for them to handle.
I explain all this when I first see these types of patients, which helps them understand that things have changed a little and there's a possibility that they may have some minor limitations. Usually they're fine with it as long as they know upfront. For those who do get back to 100%, they end up being very happy, but we have no way of knowing their exact outcome until rehabilitation is complete.
Now look at a shoulder replacement. Somebody who was 100% forty years ago and has gradually deteriorated to 30% capability may get back to a 95% or more function level after the shoulder replacement surgery and rehabilitation. They're usually completely thrilled with that result, so mentally they're in a very positive place about the experience.
Does age have anything to do with considering surgery?
Medical problems have much more to do with considering surgery than age. I would rather operate on a healthy 90-year-old than an unhealthy 60-year-old. If a patient has diabetes, high blood pressure, kidney problems, or heart disease, those are issues that really affect surgery, recovery, and the ability to participate in physical therapy. Some of my healthiest patients are in their 90's and are some of my greatest success stories because they're probably going to live many, many more years. They're very healthy and young at heart, so I try hard not to be an age discriminator when it comes to surgery. I'm partly biased because when she was 98 my own grandmother had surgery, did great, and lived eight years longer. After surgery she walked better than I could remember. Often the issue with my older patients is that they wish they had surgery much sooner.
What is the oldest person that you've operated on?
I repaired a hip fracture for a patient who was more than a hundred years old, and she's still doing fine. Four years ago I performed a shoulder replacement on a 94-year-old. I just saw her and she's going strong and doing great.