Sep 13, 2016

Dr. Miller: Shoulder pain and weakness. Could you have a full thickness tear of one of your shoulder muscles? We're going to talk about that next.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm Dr. Tom Miller, and I'm here with Dr. Bob Burks. Bob's a Professor of Orthopaedics here in the Department of Orthopaedics at the University of Utah. Bob, what is a full thickness tear of the shoulder?

Dr. Burks: So the rotator cuff and the muscles as they come around the shoulder, there are four of them, and they join together, which is why we call it a cuff. They're not as distinct as certain other tendons, and they can get a tear, which then becomes the full thickness tear of the rotator cuff tear, which for patients can be, but not always, but can be symptomatic.

There're basically two types of tears. One is traumatic. And so you fall off a bike, fall off a horse, and potentially anyway, you get a traumatic tear of the tendon. That's a little different animal than many rotator cuff tears that we see that are actually somewhat associated with the aging process. And so if we look at patients who are 20, virtually nobody has a rotator cuff problem. If you look at patients who are 80, virtually 60% to 70% of them will have rotator cuff problems.

And so I think that's what makes rotator cuff trouble unique is that in the person who has the a traumatic or the slow onset rotator cuff tear, many patients can function well with that. Many patients don't even know they have it, and so just because you see a tear, it doesn't mean you need treatment of that.

Dr. Miller: Well, what if one of the four muscles just separates? I mean, you have a full thickness tear. Talk about that a little bit. I would think if you had a full thickness tear that might impede the function your shoulder significantly.

Dr. Burks: It certainly can, but my grandfather died week shy of 99 with two huge rotator cuff tears, and he golfed his age at 95. So there are many people who can hit an equilibrium and function well with a rotator cuff tear, maybe not even know they have it, and still be hunting, fishing, doing other activities. And we have to sort out the patient who has pain, weakness, limitation, failure to respond to conservative management. Those are the people that we maybe have to intervene and help with their tear.

Dr. Miller: Well then, how would you identify the patient with a functional limitation that would require some type of intervention surgical or physiotherapy?

Dr. Burks: Well, they typically present to us, and so they'll have had trouble for a while and hallmarked as night pain. Everybody comes in and says, "Boy, I have trouble sleeping, and it's really bothering me there," and then they'll have trouble with certain physical activities during the day particularly over head. They may notice weakness, but it may be more just a pain issue, and then we have to be sure they have good motion. They're not stiff-frozen, as can happen.

And then once they have that, and they've failed a chance at physical therapy, strengthening of the muscles they do have, then we may have to consider intervention. And unfortunately, even as good as we feel we are putting things together, this is a significant recovery for the patient. And I think more than most of what we do this is where we have to educate the patient about how long it takes to get better, what the therapy, what the time period to be able to return activities.

This is a slower process. This is a longer return to recovery or to activity. And so people need to really hear about that upfront and know what they're getting into. Otherwise, there can be some disappointments.

Dr. Miller: Right. So it isn't as if you just go in an endoscopic layer, endoscopic and repair the tear, and the patient can expect to be back on the tennis court in about two weeks?

Dr. Burks: No, that's not . . .

Dr. Miller: So they have to be in a frame of mind to be a participant in the repair of the torn shoulder?

Dr. Burks: Absolutely. We have good studies that show that when we do a repair most of the people who retear or don't heal well from an anatomic standpoint, do that within the first six months. And once they get past that then we feel that it's a more permanent repair, so we have to have that early buy in. If somebody under a month says, "Oh, I'm tired of this whole process. I'm just going to go and start doing what I want and wait, and if it doesn't hurt, I'll be okay," there are going in a direction where we may have a high probability of failure.

Dr. Miller: Let's talk about the intensity of the postoperative therapy that patient completes the surgery, they go home, how often do they go into the physical therapist? I assume that you're sending them to a physical therapist for their follow-up treatment.

Dr. Burks: But again, we probably have the therapist be the coach and guide. So the patient really needs to be the therapist, and so they have a guideline of what they do, how much they can do, etc. But if they go to a therapist once or twice a week, and that's all they do . . .

Dr. Miller: It's not going to be enough.

Dr. Burks: . . . then the recovery is that much harder, or slower, or maybe incomplete. And so we need their buy-in that they get up Monday, they know the things they should be doing with their shoulder, and maybe they see the therapist on Wednesday, but they're working Monday and Tuesday.

Dr. Miller: Well, it sounds like you're going to have this conversation right upfront with the person before surgery because it seems to me that if they're not totally invested, it's not even worth doing the surgery almost.

Dr. Burks: That's the problem. And I sometimes chuckle with patients that will have a long conversation "Here's what we're going to do, this is how it's going to be, these are the things you need to be aware of," give them literature to look at and then on their post-op visit they'll come in, and they'll say, "Now, how long have I got to be in this sling or what?" And I know, and I've been through it enough that this isn't easy, and patients need to know that.

Dr. Miller: And how long do they have to be in that sling after their surgery?

Dr. Burks: Well, typically it's four to six weeks if there is a little bit depending on the size of the tear and how the repair was done. But even after that, I've had people say, "I'm going to go work in the yard," at six weeks, and they're not ready. They'll start to pull things apart. So even out of the sling, we have to have restrictions on that activity.

Dr. Miller: Well, so it sounds like there's going to be a fairly long period postoperatively where they're just immobile with that arm.

Dr. Burks: Yes.

Dr. Miller: And they've got to be ready to deal with that. So you do have the patients that buys in, you would expect it's six months, maybe a little more, if they did everything you'd asked and worked with their therapist and had their own directives for treatment and improvement, they'll do well. They would come out of that with a pretty good result.

Dr. Burks: Yes.

Dr. Miller: Very good result.

Dr. Burks: The percentage of coming out with a good result is high. However, because this is a little bit of an aging process and can occur, and there's genetic predispositions that people with certain genetic expression can have rotator cuff problems at a higher likelihood than other patients, when you start factoring all those things in, unfortunately, we do have patients down the road who maybe aren't doing as well as we'd like, and they're multifactorial. Why that may be, but this is a difficult problem to generalize "Everybody does great."

It's not a broken ankle that screws, bone heals, people do well. There are other reasons that someone may have this tear, and so most patients do well, but we certainly have those with struggles.

Dr. Miller: But to give them the best chance of repair they have to go through a prolonged period of treatment.

Dr. Burks: No question.

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