Lourdes orthopedic and sports medicine programs are determined to keep their patients rolling.
They seek to help each individual to understand the natural course of their condition, to guide healing, and to fix or renew structures and tissue as needed with minimal disruption and the fullest, promptest possible return to health and activity.
Listen in as Dr. Sean McMillan discusses the latest techniques for shoulder repair.
An Update On The Latest Techniques For Shoulder Repair
From the Show: Lourdes Health Talk
Summary:
Air Date: 12/6/15
Duration: 10 Minutes
Transcription:
Melanie Cole (Host): As interventions for conditions of the joints, bones and muscles improve, more people are able to get care for conditions that might once have been written off as inevitable or permanent. My guest today is Dr. Sean McMillan. He is the Chair of Orthopedic Sports Medicine at Lourdes Health System. Welcome to the show, Dr. McMillan. Tell us a little bit about the shoulder joint. It’s a complicated joint with many, many movements. What goes wrong for the most part with the shoulder?
Dr. Sean McMillan (Guest): Sure, Melanie. The shoulder is a ball and socket joint that basically works for two purposes: one is for stability and one is for power and strength. In our younger population under the age of 40, it’s mainly more of an instability problem we see with tears to the labrum. But, over the age of 40, we find attritional types of injuries to the rotator cuff. It’s important to classify our patients based on what they symptomology is.
Melanie: People hear that word rotator cuff all the time. What is the rotator cuff?
Dr. McMillan: The rotator cuff is actually a group of four muscles that actually give the shoulder power and stability. There’s four of them there but the one that gets all of the attention is something called the “supraspinatus”. It’s in charge of giving you the ability to raise your arm over your head as well as carry things and keep things over your shoulder.
Melanie: What goes wrong with the supraspinatus and the other muscles of the rotator cuff? Is this mostly acute, hot injury – something that happens – or is it mostly chronic overuse from doing things too often or in a wrong way?
Dr. McMillan: Surprisingly, it’s actually more of the latter. When we see someone that comes in with a rotator cuff injury, the majority of the time it is something that has been building for a period of time. I give people the example of a crack in your windshield where you have just a small chink in there and then eventually it starts to propagate more and more and more. There may be one sentinel event where maybe you had a fall that makes the shoulder start hurting more than it ever did before but it’s usually a pathology that has been building. Typically, what we see is wear and tear that has been done from repetitive motion more than acute trauma.
Melanie: How would someone know if they’ve got a rotator cuff problem? They’ve got pain in their shoulder maybe when they go to put a jacket on or it’s worse at night when they roll over. When is it time to come see you?
Dr. McMillan: Like anything else, we are going to get aches and pains that will last for a couple of days. We tend to know our bodies better than anyone else. People that have pain that they haven’t experienced before that persists – and usually I say something that persists more than just a couple of days – it’s something to keep an eye on. The biggest hallmark signs I point to is a dramatic loss in motion or a dramatic loss in strength. If yesterday, you were able to pick up a five gallon jug and all of the sudden you can’t now, that’s something to be concerned about. Activities of daily living, like you mentioned, putting on a jacket, being able to reach across your body to shower – those are all things that we’ll see. If they tend to continue on at a more rapid decline, that’s when I really want you to get in front of me so that I can examine you and sort of pinpoint what we see and what’s going on.
Melanie: What’s the first line of defense, Dr. McMillan? Do you use cortisone shots? Do you recommend anti-inflammatories? What do you do first?
Dr. McMillan: If I’m giving someone a consult the first time I see them or if I speak to them over the phone, usually its anti-inflammatory properties. Whether it’s an oral anti-inflammatory or a cream anti-inflammatory, those work well. We tend to use a little bit of ice to calm down some of the inflammation. We really try to get to the root of what the problem is. More often than not, there has been an attrition of the muscles in the shoulder girdle. You know, the muscles in the back of the shoulder that tend to get a little soft. What we’ll do is try to do a little bit of therapy to get the shoulder strong there. If that fails and they are starting to progress down in a negative spiral, we’ll consider things like injections or imaging such as MRIs. The staple is usually an x-ray and some sort of anti-inflammatory medicine and that will treat the majority of the symptoms that we see at the sight.
Melanie: Does a rotator cuff injury heal itself or, if it’s a tear, does it just generally not heal?
Dr. McMillan: That’s a great point. It’s really in the wording when we talk about rotator cuff tearing that matters. If you look at an MRI of a patient, you might someone that has a full thickness tear. In a young, healthy person that will not heal on its own and that’s when surgery is warranted. But, there is a full spectrum of tearing outside of that, whether it’s a half tear, or 50% tear, a 70% tear, a 20% tear, and that’s where having your doctor look at you and examine you and come up with an algorithm based on how to treat you - the individual - is warranted. Not every partial tear requires surgery, but some do, particularly, if they fail to respond to conservative measures for more than three months.
Melanie: What would you do surgically? What are the interventions? Are we still opening up the shoulder? Are we using arthroscopic means? Are there mini open repairs that you can do?
Dr. McMillan: Again, there is an entire spectrum but in my hands the treatment is arthroscopic and that’s done through about three or four poke holes about the size of your pinkie nail. It generally takes about a half hour to 40 minutes to do. When we are in there, we are looking for a couple things. We know that most patients that have a rotator cuff injury have some sort of bony spur that sort of is right where the rotator cuff tear is. This tends to lead to the recurrence of injury if we don’t address it. So, we’ll remove the bone spur. From there, we’ll evaluate the tissue and see if it is a partial tear or full tear and what needs to be done. One of the great things about medicine is, we’re in an age of advancing biologics. I try to incorporate that into my practice. What I mean by that is, no longer do we need to just do a full thickness rotator cuff repair on patients the way we used to which had a six month recovery. We’re starting to add biologic agents to our rotator cuff repairs which actually can cut the healing time in half. It’s really exciting to see the results we’re getting with our patients.
Melanie: Dr. McMillan, how many cortisone shots can a person get before you say to them, “It’s enough now. We have to go in and do something about it?”
Dr. McMillan: I get that question all the time and the truth is, you’re looking at the individual but we try to limit it to maybe one injection before considering a surgical intervention, maybe two, depending on the pathology there. What I tell patients is, cortisone is meant to either work or not. What I mean by that is, if I give you an injection for a bursitis and we do a physical therapy program and you get better and it lasts, that is the purpose of the cortisone. But, if the cortisone wears off in three to four weeks and you’re right back in the same pain threshold, even in spite of the conservative measures that we are doing, that’s more of a Band-Aid then and I don’t want to just mask something that’s going on. I want to treat the root cause of it. I really look at the patients individually and I try to limit it to one, maybe two, depending on what their problem is.
Melanie: Now let’s speak about prevention because even in sports they limit the amount of pitch because of shoulders for pitchers. There’s overuse. People are sports-specific training. Even in golf, for the older population, they hit the ground once and they feel it up there in their shoulder. How can we prevent some of these rotator cuff and shoulder injuries and overuse problems that we’re seeing?
Dr. McMillan: Absolutely. In our younger patients – our kids, our high school guys, even our college guys – the key is diversifying. We’ve become a society where we are so focused on being the best at what we do that we’re no longer playing different sports. What’s happening is we’re not getting that muscle confusion. Instead, we’re getting rote memory in our muscles. We’re finding that these overuse injuries tend to happen because we have muscle imbalances. If you use the same muscles over and over again and don’t give them a break, it tends to lead to more of a rapid breakdown. So, what I encourage in my younger athletes is playing baseball one season, maybe football or basketball another and not doing the same sport year round. It was done for years and years and years in the past and we had great athletes that were turned out in the major leagues and I think there is still something to be said for that. Regarding our older patients, again it’s awareness. It’s understanding that there are normal aches and pains that we’ll feel but then, there’s something else that might be going on. Getting checked out by your physician, getting into a regimented strengthening program, whether it’s on your own or with a therapist is really important. What we’ll find is, if we let our muscles go – again, particularly the back muscles, the upper shoulder muscles – those are the ones that will lead to problems down the road. If we take our sports seriously, we need to take our rehab serious as well. That’s keeping our shoulders strong.
Melanie: In just the last few minutes, Dr. McMillan—and, it’s so well put and such great information – please give your best advice for people about their shoulders: keeping them strong and healthy and why they should come to Lourdes Health System to see you.
Dr. McMillan: Sure. Keeping your shoulders strong is more than just words. It’s understanding what can go wrong with the shoulder. When I’m educating a patient, I advise them you can get the same workout and same strength in your shoulder by stopping at 90 degrees or stopping at shoulder height. We don’t need to force our shoulders to go up over our head to get a good workout with a weight. In fact, I like to recommend a much lower weight and a higher repetition for the workout keeping it at shoulder height. In doing so, we limit the possibility of doing damage to our shoulder but we also focus on strengthening our shoulder. We’re not training for bodybuilding competitions in most instances; instead, we are trying to prepare our shoulder for day to day activities and for fun activities. That’s what we need to do is make sure we work all the muscles in our shoulder girdle and make sure we keep it at a safe level. Getting to the second point of your question, at Lourdes Health Systems, we are really blessed with the ability to provide our patients with cutting edge activities. We talked a little bit about this before but we are using biologic activities, biologic agents – whether it’s PRP injections, where we use your own blood as a healing factor in a non-surgical way to make our bodies regenerate or whether it’s in surgery using cutting edge technologies through minimally invasive techniques to get you back to your sport and get you back to your life quicker. We don’t want to see you down. We want to see you happy. One of the things we provide here at Lourdes is individualized care where the doctor sees the patient. The doctor and the patient then design a program that will get them back to whatever their activity is. We are very close knit here. We work well with our physician assistants and our operating room team, should the need arise. But, our goal is to avoid a surgery, if possible, and we think we do a good job of that.
Melanie: Thank you so much, Dr. McMillan. You’re listening to Lourdes HealthTalk with Lourdes Health System. For more information you can go to Lourdesnet.org. That’s Lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): As interventions for conditions of the joints, bones and muscles improve, more people are able to get care for conditions that might once have been written off as inevitable or permanent. My guest today is Dr. Sean McMillan. He is the Chair of Orthopedic Sports Medicine at Lourdes Health System. Welcome to the show, Dr. McMillan. Tell us a little bit about the shoulder joint. It’s a complicated joint with many, many movements. What goes wrong for the most part with the shoulder?
Dr. Sean McMillan (Guest): Sure, Melanie. The shoulder is a ball and socket joint that basically works for two purposes: one is for stability and one is for power and strength. In our younger population under the age of 40, it’s mainly more of an instability problem we see with tears to the labrum. But, over the age of 40, we find attritional types of injuries to the rotator cuff. It’s important to classify our patients based on what they symptomology is.
Melanie: People hear that word rotator cuff all the time. What is the rotator cuff?
Dr. McMillan: The rotator cuff is actually a group of four muscles that actually give the shoulder power and stability. There’s four of them there but the one that gets all of the attention is something called the “supraspinatus”. It’s in charge of giving you the ability to raise your arm over your head as well as carry things and keep things over your shoulder.
Melanie: What goes wrong with the supraspinatus and the other muscles of the rotator cuff? Is this mostly acute, hot injury – something that happens – or is it mostly chronic overuse from doing things too often or in a wrong way?
Dr. McMillan: Surprisingly, it’s actually more of the latter. When we see someone that comes in with a rotator cuff injury, the majority of the time it is something that has been building for a period of time. I give people the example of a crack in your windshield where you have just a small chink in there and then eventually it starts to propagate more and more and more. There may be one sentinel event where maybe you had a fall that makes the shoulder start hurting more than it ever did before but it’s usually a pathology that has been building. Typically, what we see is wear and tear that has been done from repetitive motion more than acute trauma.
Melanie: How would someone know if they’ve got a rotator cuff problem? They’ve got pain in their shoulder maybe when they go to put a jacket on or it’s worse at night when they roll over. When is it time to come see you?
Dr. McMillan: Like anything else, we are going to get aches and pains that will last for a couple of days. We tend to know our bodies better than anyone else. People that have pain that they haven’t experienced before that persists – and usually I say something that persists more than just a couple of days – it’s something to keep an eye on. The biggest hallmark signs I point to is a dramatic loss in motion or a dramatic loss in strength. If yesterday, you were able to pick up a five gallon jug and all of the sudden you can’t now, that’s something to be concerned about. Activities of daily living, like you mentioned, putting on a jacket, being able to reach across your body to shower – those are all things that we’ll see. If they tend to continue on at a more rapid decline, that’s when I really want you to get in front of me so that I can examine you and sort of pinpoint what we see and what’s going on.
Melanie: What’s the first line of defense, Dr. McMillan? Do you use cortisone shots? Do you recommend anti-inflammatories? What do you do first?
Dr. McMillan: If I’m giving someone a consult the first time I see them or if I speak to them over the phone, usually its anti-inflammatory properties. Whether it’s an oral anti-inflammatory or a cream anti-inflammatory, those work well. We tend to use a little bit of ice to calm down some of the inflammation. We really try to get to the root of what the problem is. More often than not, there has been an attrition of the muscles in the shoulder girdle. You know, the muscles in the back of the shoulder that tend to get a little soft. What we’ll do is try to do a little bit of therapy to get the shoulder strong there. If that fails and they are starting to progress down in a negative spiral, we’ll consider things like injections or imaging such as MRIs. The staple is usually an x-ray and some sort of anti-inflammatory medicine and that will treat the majority of the symptoms that we see at the sight.
Melanie: Does a rotator cuff injury heal itself or, if it’s a tear, does it just generally not heal?
Dr. McMillan: That’s a great point. It’s really in the wording when we talk about rotator cuff tearing that matters. If you look at an MRI of a patient, you might someone that has a full thickness tear. In a young, healthy person that will not heal on its own and that’s when surgery is warranted. But, there is a full spectrum of tearing outside of that, whether it’s a half tear, or 50% tear, a 70% tear, a 20% tear, and that’s where having your doctor look at you and examine you and come up with an algorithm based on how to treat you - the individual - is warranted. Not every partial tear requires surgery, but some do, particularly, if they fail to respond to conservative measures for more than three months.
Melanie: What would you do surgically? What are the interventions? Are we still opening up the shoulder? Are we using arthroscopic means? Are there mini open repairs that you can do?
Dr. McMillan: Again, there is an entire spectrum but in my hands the treatment is arthroscopic and that’s done through about three or four poke holes about the size of your pinkie nail. It generally takes about a half hour to 40 minutes to do. When we are in there, we are looking for a couple things. We know that most patients that have a rotator cuff injury have some sort of bony spur that sort of is right where the rotator cuff tear is. This tends to lead to the recurrence of injury if we don’t address it. So, we’ll remove the bone spur. From there, we’ll evaluate the tissue and see if it is a partial tear or full tear and what needs to be done. One of the great things about medicine is, we’re in an age of advancing biologics. I try to incorporate that into my practice. What I mean by that is, no longer do we need to just do a full thickness rotator cuff repair on patients the way we used to which had a six month recovery. We’re starting to add biologic agents to our rotator cuff repairs which actually can cut the healing time in half. It’s really exciting to see the results we’re getting with our patients.
Melanie: Dr. McMillan, how many cortisone shots can a person get before you say to them, “It’s enough now. We have to go in and do something about it?”
Dr. McMillan: I get that question all the time and the truth is, you’re looking at the individual but we try to limit it to maybe one injection before considering a surgical intervention, maybe two, depending on the pathology there. What I tell patients is, cortisone is meant to either work or not. What I mean by that is, if I give you an injection for a bursitis and we do a physical therapy program and you get better and it lasts, that is the purpose of the cortisone. But, if the cortisone wears off in three to four weeks and you’re right back in the same pain threshold, even in spite of the conservative measures that we are doing, that’s more of a Band-Aid then and I don’t want to just mask something that’s going on. I want to treat the root cause of it. I really look at the patients individually and I try to limit it to one, maybe two, depending on what their problem is.
Melanie: Now let’s speak about prevention because even in sports they limit the amount of pitch because of shoulders for pitchers. There’s overuse. People are sports-specific training. Even in golf, for the older population, they hit the ground once and they feel it up there in their shoulder. How can we prevent some of these rotator cuff and shoulder injuries and overuse problems that we’re seeing?
Dr. McMillan: Absolutely. In our younger patients – our kids, our high school guys, even our college guys – the key is diversifying. We’ve become a society where we are so focused on being the best at what we do that we’re no longer playing different sports. What’s happening is we’re not getting that muscle confusion. Instead, we’re getting rote memory in our muscles. We’re finding that these overuse injuries tend to happen because we have muscle imbalances. If you use the same muscles over and over again and don’t give them a break, it tends to lead to more of a rapid breakdown. So, what I encourage in my younger athletes is playing baseball one season, maybe football or basketball another and not doing the same sport year round. It was done for years and years and years in the past and we had great athletes that were turned out in the major leagues and I think there is still something to be said for that. Regarding our older patients, again it’s awareness. It’s understanding that there are normal aches and pains that we’ll feel but then, there’s something else that might be going on. Getting checked out by your physician, getting into a regimented strengthening program, whether it’s on your own or with a therapist is really important. What we’ll find is, if we let our muscles go – again, particularly the back muscles, the upper shoulder muscles – those are the ones that will lead to problems down the road. If we take our sports seriously, we need to take our rehab serious as well. That’s keeping our shoulders strong.
Melanie: In just the last few minutes, Dr. McMillan—and, it’s so well put and such great information – please give your best advice for people about their shoulders: keeping them strong and healthy and why they should come to Lourdes Health System to see you.
Dr. McMillan: Sure. Keeping your shoulders strong is more than just words. It’s understanding what can go wrong with the shoulder. When I’m educating a patient, I advise them you can get the same workout and same strength in your shoulder by stopping at 90 degrees or stopping at shoulder height. We don’t need to force our shoulders to go up over our head to get a good workout with a weight. In fact, I like to recommend a much lower weight and a higher repetition for the workout keeping it at shoulder height. In doing so, we limit the possibility of doing damage to our shoulder but we also focus on strengthening our shoulder. We’re not training for bodybuilding competitions in most instances; instead, we are trying to prepare our shoulder for day to day activities and for fun activities. That’s what we need to do is make sure we work all the muscles in our shoulder girdle and make sure we keep it at a safe level. Getting to the second point of your question, at Lourdes Health Systems, we are really blessed with the ability to provide our patients with cutting edge activities. We talked a little bit about this before but we are using biologic activities, biologic agents – whether it’s PRP injections, where we use your own blood as a healing factor in a non-surgical way to make our bodies regenerate or whether it’s in surgery using cutting edge technologies through minimally invasive techniques to get you back to your sport and get you back to your life quicker. We don’t want to see you down. We want to see you happy. One of the things we provide here at Lourdes is individualized care where the doctor sees the patient. The doctor and the patient then design a program that will get them back to whatever their activity is. We are very close knit here. We work well with our physician assistants and our operating room team, should the need arise. But, our goal is to avoid a surgery, if possible, and we think we do a good job of that.
Melanie: Thank you so much, Dr. McMillan. You’re listening to Lourdes HealthTalk with Lourdes Health System. For more information you can go to Lourdesnet.org. That’s Lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
