Podcast: Rotator Cuff Stuff

Podcast Transcript

Hello and welcome to The Bone and Joint Playbook with Dr. John Urse, Tips for Pain Free Aging. Today’s topic is Rotator Cuff Stuff, let’s listen in.

Terry: Well hello listeners. I’m Terry O’Brien and welcome to another episode of The Bone and Joint Playbook with Dr. John Urse. Dr. John Urse what are we talking about today?

Dr. Urse: Well Terry, we’re talking about rotator cuff stuff.

Terry: Oh my gosh, what makes you an expert in rotator cuff stuff?

Dr. Urse: Well, I don’t know if I’m an expert, but I certainly have a lot of experience taking care of shoulder problems. I have been in practice for 34 years doing orthopedic surgery here in Dayton Ohio. I have been doing shoulder arthroscopy, where we look in the shoulder with a light for that whole time. Many of the advances we do, which we will talk later about having to fix these sometimes, involve doing that through a scope where we look in with little holes to the shoulder to make the shoulder better. Now occasionally we do open procedures on the shoulder for the rotator cuff or for joint replacements when there is arthritis with some of the rotator cuff problems. For the most part, most orthopedic surgeons see a lot of shoulders, they’re common injuries and I’ve also heard you moan and groan about yours a few times.

Terry: That is why I’m excited about this topic. I go to bed, lay on my shoulder and it hurts, wake up in the morning and it hurts. So, this is one topic I am very excited to talk about. Just curious, you say you solve a lot of shoulder problems, out of the people that walk through the door, how many are coming in with shoulder problems versus hips or knees.

Dr. Urse: I would probably say 20%, it’s a good number. Especially if you’re seeing that kind of practice. Now if you’re a foot surgeon you’re probably not seeing those people. Shoulders are common injuries; you use your arms a lot in a repetitive forward or overhead position. We are going to talk about something called impingement where something rubs against something, kind of like a rope hitting the edge of a jagged rock. Some people have above their shoulder in their shoulder blade either a curve or a little spur that digs into the rotator cuff which is a rope type attachment that helps lift your arm. So, the function of that muscle is to help lift your arm. Shoulders are much more mobile joints than other joints that you have. Our ability to climb a tree is awesome because we can move the arm overhead or behind us, and you have probably seen what people can do in gymnastics with their shoulders. Also, because it is a very shallow joint it has a lot of freedom of movement, it can also slip out of place and sometimes dislocate or partway pop out and that is a different topic where the shoulder isn’t stable and is an unstable joint. Today, the things that hold that in place are the rotator cuff muscles. The cuff is a group of muscles, there are four of them, one in the front, two in the back, and one on the top. The one on the top is the supraspinatus tendon and that is the thinnest rotator cuff muscle, and it seems to be the one most commonly injured and it is the one that rubs most commonly against the upper shoulder blade. Part of what we are going to talk about later are things that therapy can do to help our posture to pull the shoulder blade back, much like you would see the girls in finishing school with the book on their head. That posture is good for your shoulder, conversely slouching forward brings that bone spur closer to the rotator cuff so that irritates this cushioning sack called the bursa. You may be having some bursitis symptoms at night where the rotator cuff may or may not be part of the problem, it may be more bursitis instead of what is called tendinitis. So, in the anatomy terms to keep this simple, muscles help contract they move joints that’s why we move our arms, legs, wrist, and elbows. The attachment of the muscle to the bone is called a tendon which is a ropey attachment. That rope is what gets frayed or eventually torn and we are going to talk later about how we get these injuries over time. Sometimes it’s a slower process, sometimes it’s more acute or traumatic process with an injury like a fall, etc.

Terry: So, you answered basically kind of the question what a rotator cuff is and what does it do. Is there anything else you want to elaborate on with that?

Dr. Urse: Well just to let people know that we’re going to try and ask you questions like is your problem more pain and discomfort? Or is it more weakness and loss of function?

Terry: For me it’s more pain.

Dr. Urse: Well, that’s better for you because pain responds well to physical therapy, types of injections we will talk about later, and certain activity modifications. So, if you’re an assembly line worker putting a part on a shelf 1500 times an hour, you’re putting your shoulder into the impingement arc overhead that irritates the rotator cuff. We may say that you’ve got some bursitis of the shoulder or maybe inflammation of the rotator cuff called tendinitis and by avoiding positions above a right angle forward or away from your body you’re not putting the shoulder in a bad position. We would tell you to work lower, if you’re a barber you could stand on a step stool so you’re working down below shoulder level instead of keeping your arms above shoulder height when you have someone in a chair that you’re working on their hair.

Terry: So, what causes a rotator cuff to tear? What is the thing I could do wrong that would cause this injury?

Dr. Urse: Well, you could fall out of a tree and land on your shoulder and that would rip your tendon and you would have what is called an acute or complete tear of the tendon. So, we are going to talk about two types of tears. One is called tendinitis or partial tears. I tell people a rope can have a partial tear so if you’re hanging off a cliff with a rope and a mouse starts chewing on your rope and you think wait a minute, I’m hanging on this rope. You shoot the mouse, but you have half a rope now and that’s not a normal rope and if it hits the edge of a rock over the cliff that rope can abrade over time and become worse, and it can eventually completely tear. So, one is an acute injury or traumatic fall, maybe your shoulder dislocates, or you have an injury on an outstretched hand which are probably not as common as what we do in everyday life which is repetitive micro trauma. We have talked about this in other body parts like a cross country runner who repetitively pounds on his lower extremities with running, a person who does repetitive overhead use like a baseball pitcher and an assembly worker are doing repetitive trauma to an area. We have two people in history that we can thank for shoulder knowledge. One is a guy named Ernest Codman who in the early 1900’s looked at the anatomy of the shoulder and looked at where the blood vessels are and at the front of the shoulder is an area where the blood flow isn’t good, and that area tends to tear more commonly. We talked that thin muscle at the top called the supraspinatus, so as that area where healing isn’t great repetitively abrades or rubs you can get tendinitis or partial tearing of that tendon which causes pain with arm movement above usually a right angle either forward or away from your body or by laying on your shoulder at night. It also is squeezing that cushioning sack called a bursa and that is all bursa’s do is cushion body parts. We have a bursa at the end of our elbow, at the end of our knee, the outside of our hip and different body parts. Most problems in the shoulder are more than just the bursa just like when we talked about the hip bursitis, it’s usually more the tendon like in the hip it is the glute tendon we call that the rotator cuff of the hip and there is a different podcast on that. So, in the spectrum of how I got a rotator cuff problem, I always break it into decades. So, if you’re in your early twenties and your buddy says I’m moving into my college dorm can you help move furniture. You move furniture all day and the next day your shoulder is sore from moving bunk beds or dressers. Your body has then developed edema or swelling from overuse for a day and when you’re in your twenties that goes away in a day or two and you’re fine. So, in the earliest phase of repetitive overuse just recovers quickly. Now, you’re working for Allied Van Lines, and you move furniture every day for fifteen years and you’re in your thirties and forties. Your shoulder now has repetitively overloaded that rotator cuff tendon and you now have tendinitis but a scarring called partial tearing or that rope is starting to get more abraded and if you have that anatomical problem with a bone spur above it that makes it more prone to impingement, now your starting to get into a shoulder that doesn’t recover as quickly when moving your buddies furniture.

Terry: So, it sounds like overtime the rotator cuff becomes more sensitive and more painful.

Dr. Urse: Yes, because we are living longer and doing more. Now when you’re in your fifties and sixties we are now getting to the point where you can’t put a dish on a shelf, reach the back of your hair and can’t play pickleball and you’re not happy. People have then lost function and we talked about pain versus function. Function loss brings people to the doctor more quickly because they can’t do the things they want to do. You might say I retired to play golf, but I can’t lift my arm or play pickleball and those people need a lot more aggressive workup or evaluation. Those are the patients we might examine in the office and say, gee Terry you have more than just pain lifting your arm, you can’t even hold it against gravity. It’s that weak when pushing against your arm you now have weakness with pain and there might be a tear of one of those ropey attachments of the rotator cuff is now disrupted and much like a rope that lifts an awning, if the rope is torn, you’re not lifting the awning, right? So that weakness is something we can find with either an ultrasound test in the office or with an MRI which is a radio wave test to look at the details of the soft tissues. We would always x-ray the shoulder in the office first to look for calcium deposits, bone spurs or arthritis in the joint. We also examine you and make sure it’s not a different body part like your neck, heart, lungs, or some other reason your shoulder hurts, it doesn’t always have to be your rotator cuff all the time.

Terry: That was going to be my next question. What else could it be if it wasn’t my rotator cuff causing me to wake up at night in pain?

Dr. Urse: Well, it could be a couple things. Some people have acid reflux believe it or not your esophagus and the stomach acid going back, because you don’t elevate the head of your bed a little bit and you have been taking Motrin for your sore shoulder that isn’t really isn’t from the shoulder at all. Now the Motrin is irritating your stomach and you’re taking antacids every night for the acid reflux. It could be issues with your heart, neck, pinched nerves that can affect your shoulder if they’re from the upper neck area. We have talked in the past about pinched nerves that effect your hip in the lower back area. The spine is always a common mimicker of shoulder, elbow, hand, or arm pain if the pinched nerve coming off the spine is causing those symptoms. So, an exam would include looking at your neck and shoulder. We would ask you if it’s when you’re moving your arms, laying on it, and what are you doing at night that causes the pain or during the day things that aggravate it. Is it mostly overhead work, repetitive forward work, or its not painful, but you cannot use it or lift it which means it might be a torn tendon that needs to be evaluated. Again, some things don’t move because the nerve to the muscle is damaged, so nerve injuries are another cause for lack of movement. A good exam or a nerve test can show a nerve problem and sometimes it’s both. We have people with neck and shoulder problems both and we say, “Terry, I think you have a shoulder problem, but when you turn your neck to the left, you’re not happy on that either.” We always say in medicine if you find two problems look for three and sometimes that’s why your healthcare provider whether it’s your physician assistant, nurse practitioner, chiropractor, family doctor or orthopedic surgeon should look you over for this. Things like the heart mostly effect the left shoulder and ironically your heart doesn’t affect the right, but your gallbladder which is under your diaphragm on the right, can make right shoulder pain. So, there are things a healthcare provider would know or look for or ask you in your history like do fatty or spicy foods bother you and if you have a certain risk factor for gallbladder issues. So, when we examine or talk to patients we are trying to pinpoint if this is a shoulder problem or does the history tell me to look other places or does the physical exam tests show me weakness or pain with certain things. Maybe your shoulder is slipping out and popping out of place and then it’s not even the rotator cuff. Remember if your young people moving furniture are not tearing their rotator cuff. If a thirty-two-year-old comes in with shoulder pain, they are more likely to have instability of the shoulder where it might be slipping out or it could be the labrum inside the joint. There are other things that go wrong with throwing activities or sports that aren’t the rotator cuff. That is where the healthcare provider needs to do the appropriate test and evaluation to pinpoint where the problem is.

Terry: Two follow up questions. Salonpas and Icy Hot, when I put it on my shoulder is it doing anything at all?

Dr. Urse: Sure. There are two things, ice is always good for most things in orthopedics. Occasionally a muscle will respond to a heating pad like your low back, but I don’t use a lot of heat on joints, because I think it increases blood flow and makes inflammation worse. Ice is your friend before a workout, after a workout, and definitely after a surgery. I show pictures of snow and icicles on my lectures, because that is the message I want people to see, ice is good. The second thing is Salonpas, which is a Novocain patch that goes on much like Novocain at the dentist that they call lidocaine. You can get that over the counter which is a little patch you can put on the area of the body, and it lasts about twelve hours, and you can buy that without a prescription at your local stores. Just like your lip goes numb at the dentist so they can drill into your tooth, using Novocain is an anesthetic or numbing device. Now, what it doesn’t do is penetrate all the way down to the joint or into your hip really well. When you go to therapy and they do ultrasound or try to work in some cortisone cream into your hip, it only gets in an inch or two, it probably won’t get in four inches. Based on your anatomy as we have different people with different body habitus’ that may respond better to topical treatments on the skin.

Terry: So, I am now in my early sixties, and I use to be able to throw a ball pretty good, now when I go out and throw a ball it doesn’t go very far and it kind of hurts to throw it. I feel like I am awkwardly throwing it these days. Is that a rotator cuff? I know you cannot diagnosis me over that.

Dr. Urse: I can tell you that most throwing difficulties can be part of the rotator cuff which helps not only power the shoulder, but hold it in place and stabilize it.That is why the exercises we are going to talk about later will help a rotator cuff patient, but also a patient whose shoulder is unstable or partway slipping out. Those stabilizing muscles are in the back, front and top and we are trying to hold the ball in place if it is unstable or loose. In your case it could be inside the joint. People who throw like baseball players, softball players, tennis, volleyball, and racquetball players all wind up to throw, but sometimes they don’t complete the arc of the throw down so the back of the shoulder gets tight and pulls against this lip thing called the labrum. We talked about labral tears previously. There is something in the shoulder called a SLAP tear which is a superior labrum that tears from anterior to posterior and mercifully its abbreviated SLAP. Thats an inside of the joint problem, but a lot of baseball players have it because they don’t stretch the back of their shoulders. We can prevent those tears by a good exam showing that you need to stretch the back of your shoulder. Then you all of a sudden don’t hurt when you throw because your ball is better centered in the joint and now your back throwing the ball from first base to shortstop, now you might not be throwing the ball to home from left field, but let’s face it, Roger Clemons isn’t pitching for the Yankees anymore either and he is in his fifties. There is a point that our body parts wear down some because of the repetitive things we put them through for years.

Terry: So, if I come to you with a rotator cuff issue, or what I think is a rotator cuff issue what can you do to fix it? What are some things you can do to make my life a little better?

Dr. Urse: First thing I am going to tell you is that we need to diagnose the problem. We are going to find out if that’s torn. So, we can take an ultrasound in the office and look at the rotator cuff. We can see the muscles around the shoulder and the collarbone joint on the top called the AC joint. What we can’t see with an ultrasound is the inside part of the joint called the cartilage which wears out in arthritis, so MRI’s are more detailed for that. We may put in an injection in your shoulder. There are a couple types of injections that are useful, one is called Toradol which is a pain medicine injection. There is some evidence that cortisone is ok to put in the bursa once or twice, but cortisone in the long run is probably not helpful to the tissue. There are some studies now that show repeated cortisone shots in the shoulder can actually impair healing of a rotator cuff if it has to be fixed. So, if someone says my doctor gives me a cortisone shot in my shoulder once a month, I tell them it’s not really doing them a service if you’re going to need surgery later or your doctor probably has a boat payment because that is way too many shots. Maybe one or two a year that you can put in a body part, but not every month. The last thing would be is there are other types of injections called platelet rich plasma, we talked about PRP before.

Terry: Stem cells?

Dr. Urse: Stem cells are a little bit stronger, and you don’t need something quite that strong for a rotator cuff. There is really good evidence now that PRP can help with inflammation and healing.

There is strong evidence now that if a rotator cuff has to be fixed, it has a lower re-tear rate if you put PRP in at the time of surgery right into the repair site, kind of like holy water. We talked a little bit about some of the open-heart surgeries we do in town. Every open-heart surgery where the breastbone is closed gets a platelet rich plasma injection along the breastbone closure area as it helps healing and post op pain in the open-heart surgery patients. Some of these are put in as methods to help healing, some are meant to help prevent re-injuries, some are meant to help avoid having to fix it. So, a partial rotator cuff tear may also respond to an injection of PRP, which is much better than cortisone. Cortisone actually unravels the fibers of a ropey attachment so if you think of how ropes are wound, think of steroids or cortisone as unraveling that collagen like you would untwist a rope. Over time it is not good for a rotator cuff tendon to have a lot of steroid or cortisone shots.

Terry: What is Toradol? The other injection that you can get.

Dr. Urse: Toradol is kind of an injection form of an anti-inflammatory. It also comes in a pill form, but you can’t really take it for more than about four to five days as it is tough on your stomach. Some people with acute pain will take Toradol, a lot of ER’s give it to people. It’s a nice injection option as we also give it to people with diabetes since cortisone will raise blood sugar level and we don’t want to do that in the office. So, we may put some Toradol in the shoulder as a pain relief for that bursitis pain when you’re trying to sleep at night and then I would recommend some physical therapy which is really the mainstay of treating rotator cuff problems. Most people need to go once to a physical therapist, hopefully more or to your chiropractor to have them show you how to do the exercises to help strengthen your rotator muscles that are not torn so they can help the one that maybe torn, because not all of these need to be fixed.

Terry: You were saying before we got started that a lot of the rotator cuff issues don’t need to have surgery. So, do you have a percentage that you see coming into the office where you have to do operations on 5% or 10% of the cuff tears?

Dr. Urse: That’s a great question, Terry. The ironic thing is that we talked about later decades of life so people that are over fifty and sixty years old, if you gave people free MRI’s and said come in like we are doing now with the vaccines with the COVID stuff, we could tell people with or without symptoms that probably 30% of people would have a rotator cuff tear on MRI and a lot of them wouldn’t even have shoulder pain. With testing, we would probably find over 6 million rotator cuff tears a year in the United States, and we only operate on three hundred thousand. So, that means a lot of people get better with a tear in their rotator cuff and that’s because a small tear in the little thin muscle on the top, as long as we can rehabilitate the shoulder and make the muscles in the front stronger and then they can do some of the work for that little torn muscle. I tell people if you’re not having pain or weakness, I don’t care what your MRI shows, you don’t need it fixed. So, you now have to lower your expectations and am not going to pitch for the Yankees or install cable wiring in my ceiling and consider putting dishes lower and glasses higher, so your demands are less. If your seventy-five years old and with a bad heart, I don’t want to operate on you. I tell people that if you set your expectations low enough you will reach most of them. Just say look, grandma is not putting those dishes on the self grandpa, you do that. Grandpa, you quit working on roofs and quit working overhead or painting overhead. Those are lifestyle changes that can make your shoulder get along pretty well, and sometimes without surgery.

Terry: So, as we get towards the end of this a couple of things. How long should I wait after being diagnosed with a rotator cuff issue, what is my healing expectation and how long should that take?

Dr. Urse: That’s when we get to the when should I fix this category and again, we look at function and pain. If you’re an athlete and have a torn rotator cuff, if you want to play again it needs to be fixed. These things can take a while to heal because this has to lift your arm. There are two downsides to not fixing your rotator cuff. If you take a Kleenex, put a rip in it, and say that’s a rotator cuff tear, well over time that is going to keep ripping more if you pull the ends apart. Using it more does not make it go back together, it’s a torn tendon or ropey attachment and it can’t heal itself. If that muscle isn’t attached, it doesn’t have to do anything and it starts to get fat in it called atrophy and that’s called disuse or wasting of the muscle where it doesn’t become strong muscle again. So, if you wait too long and some people say 3-6 months is probably the window of when you should think about deciding to fix your rotator cuff. Once that fat is in the muscle, it can be in a little part of one muscle and be ok, but if it is three of the muscles and the tear is bigger than usual, and we grade our tears by small, medium, large, or massive. We grade our tears by size, larger tears with more fat or muscle wasting have poor healing and we talked about the biology people have and what effects healing. We talked about blood flow and Codmans area and we talked about the area where the blood flow is poor on the shoulder and people that make healing difficult like diabetics, smokers, poor nutrition, or people that aren’t compliant. So, if I say don’t lift your arm and wear a sling for three to six weeks, because I am going to fix the rotator cuff, it’s a lot like fixing a coffee mug handle with superglue. If you grab the handle too soon the bonding is going to come off, it has to heal and bond to be able to lift your arm. We have to protect what we do to fix it and we may want to add platelet rich plasma to improve healing also. We know in medium to large to massive rotator cuff tears, PRP reduces the re-tear rate in half so it’s really beneficial. The thing about PRP we talked about is that it is part of your blood that we draw from your arm, we would spin that, concentrate it, and put it in your shoulder directly at the repair site and then that would help healing. It may cost people a few extra dollars because it isn’t always covered. That is the type of person we talk about for surgery is the person who can’t use their arm, can’t function, can’t sleep, and can’t take a half gallon of milk out of the refrigerator. Now they have lost function and they can’t play pickleball. There is a recovery period and I tell people its three to nine months for rotator cuffs, small tears can get better in three to four months and there is a healing process which are in six-week intervals. You wear a sling or protect moving your elbow away from your body for at least six weeks that prevents you from stressing the torn tissue. Your therapist or your other arm can move your arm, so it doesn’t let your shoulder get stiff. The second six weeks you can start lifting it which is called active motion and the therapist will show you how to do that. We are not trying to make it real strong yet and at the twelve weeks mark your rotator cuff is really strong and the bonding is really good, and you can lift your coffee cup at that point. We then have to make it stronger with exercise. We use tubing, sticks, and pulleys which help get movement and strength back. I tell people that a full rotator cuff repair after a big tear is much like a baby delivery and takes about nine months and you don’t get a baby in three months, and you don’t get a normal shoulder in three months either. A shoulder has nine different movements to go through to get full recovery, especially to put a heavy box on a shelf if you’re a laborer. I tell people that light duty is easy if you’re a person that works at home on a computer, you could go back to work in a week after a rotator cuff surgery because you’re wearing a sling. There are things that workers need to know if you’re a laborer if you have to go back to a job that you’re specifically trained for. Those make take longer for recovery, but they still need to be fixed if that is what you need to do your job.

Terry: I tell you what I learned a ton today and I am actually a little happier after this conversation about what my future holds for my rotator cuff. Is there anything else you want the listener to know about the rotator cuff before we go?

Dr. Urse: I promised you two great historical features and I gave you Ernest Codman in 1911 who wrote that initial study on the rotator cuff anatomy and how we do surgery. The second guy is Charlie Neer, and he is really the father of modern-day shoulder replacement and some of the things we talked about with the impingement and tendinitis and tearing over time and how it is a spectrum of misery as we age. The one thing that is a different rotator cuff category is a person with a large tear, perhaps with fat in it who also has arthritis in the joint. That makes it not a very good shoulder to try and fix the rotator cuff. As we get older if we have arthritis in the joint, much like a hip or knee, there is a shoulder procedure called a reverse ball and socket procedure or called a reverse shoulder arthroplasty. What that does is instead of just replacing the joint like a joint replacement with a ball and socket, the ball is actually on the socket side and is reversed inside. We do not try and fix the rotator cuff, we use the round part of the shoulder called the deltoid, you might feel the round muscle on the outside of the shoulder. That is what is used to move the arm and you kind of outsmart the body by using different muscles to move it or lift it. That is a bigger procedure, but it is a great procedure for an older person who has significant arthritis in the joint because you solve two problems. With the reverse you replace the joint where the arthritis is, but you don’t try to fix a huge tear in a bedsheet that isn’t going to come together or has a lot of fat that isn’t going to heal anyways. So, in that case you talk to your doctors about making sure you don’t have too much arthritis and make sure the cuff is repairable by MRI, physical exam or by the doctor’s experience fixing them.

Terry: Well great. Dr. John Urse, thank you so much for doing this again. I look forward to our next podcast. Any idea what we are going to talk about next time?

Dr. Urse: Well, we are going to do a couple topics, one will be on indications for spine surgery because I know necks and low backs are always things where people don’t want to think of surgery but occasionally it is important. We are also going to do common sports injuries which will be head to toe common injuries you see on the football field, baseball field and in the gym with simple injuries that people might remember someone in their family or themselves have had. We also encourage people to look at the website and leave some suggestions there to make sure that is available.

Terry: So, the website is www.drjohnurse.com so if you ever want to reach out to Dr. Urse and maybe leave a note about a topic you would like him to cover I’m sure there is a spot on there to do that. Thank you very much it has been an enjoyable session and I look forward to throwing that ball at you later.

Dr. Urse: Ok, thanks Terry. Have a great day!