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Scott Liscomb (Host):  Hello and welcome from wherever you are tuning in and thanks for listening to the Well Within Reach Podcast series by Riverside Healthcare. My name is Scott Liscomb, I’m going to be your host today. I’m joined by Dr. Joshua Miller, an MD and PhD in General Orthopedics. As I mentioned, Dr. Miller is a General Orthopedic Surgeon at Riverside Orthopedic Specialists. Dr. Miller received his Doctor of Medicine degree from the University of California in San Francisco and completed an internship in general surgery, an orthopedic surgery residency and a research fellowship in orthopedic surgery at the University of Michigan System in Ann Arbor. Dr. Miller, welcome to the podcast.

Joshua Miller, MD (Guest):  Thank you.

Host:  Today, we’re discussing rotator cuff injury and repair but before we jump into that, I was wondering if you could just tell our listeners a little bit about yourself and why you decided to focus in orthopedic care.

Dr. Miller:  Oh, that’s a great question. I am an orthopedic surgeon and I recently moved here about a year ago from the University of Michigan and I focus on disorders of the shoulder and the hip and the knee and the ankle. And it was something that it just grabbed me in medical school. I think I liked every discipline that I came across in medicine. I really liked it a lot and I probably could have been happy doing any of them but once I did an orthopedic rotation, I just never looked back from that. I was just a great thing.

Host:  Yeah. Very interesting. Well as I mentioned, we’re talking about rotator cuff injury and repair today. And I’m sure any of our listeners who may have had a rotator cuff injury would know, it can be an extremely painful injury to have. Close to two million people in the US went to their doctors over the last year because of a rotator cuff problem and the injuries from what I understand are most often in people who perform repeated overhead motions either on their job or in sports and so Dr. Miller, I was wondering if you could provide maybe a general explanation of what the rotator cuff is and what the functions are that it plays in the shoulder?

Dr. Miller:  Yeah, so the upper extremity and the shoulder in particular is a really interesting joint because it’s very different than the lower extremity. In the lower extremity, we have a very large ball and socket joint that attaches the lower limb to the pelvis through the hip joint. And it’s a very deep socket and a large ball that gives you a lot of range of motion but extremely good stability. And in the shoulder, the shoulder, the entire upper extremity is attached to the rest of your body only through a very, very small joint and the rest of the attachment is really muscular.

So, the shoulder is very dependent on muscle balance and many of the problems around the shoulder are as a result of imbalance and sometimes that actually involves an injury or a tear in a tendon. So, for example, the rotator cuff is a set of muscles that originates from the shoulder blade, the front and the back and the top of the shoulder blade and they extend out and wrap around the ball of the humerus and form a cuff of tendon there. And the shoulder joint unlike the hip joint, is a ball and a socket but it’s a very shallow flat socket and that has the potential for tremendous motion but it’s intrinsically unstable unlike that hip joint.

And therefore, the rotator cuff it’s prime job is to as the ball slips out of place, it contracts, and it balances the ball and centers it back on the socket. A very important part of that is balancing the big power muscle of the shoulder which is the deltoid muscle. And the deltoid, it gives you the power to raise your arm but it’s prime direction of pull is basically up and so without the function of the rotator cuff, the ball will rise in the socket and it will impinge against the structures in the superior part of the socket.

And so the rotator cuff pulls downward, and it balances that out. It also probably plays a role in initiating the movement of the arm away from the body to the point where the big muscle, the deltoid, can take over and finish the job of raising it.

Host:  So, a lot of range of motion with that rotator cuff, a lot of muscle and tendon there. So, with that being said, the complexity of the rotator cuff, those muscles and tendons; how easy is it to tear one of those muscles or tendons within the rotator cuff?

Dr. Miller:  Great question. And I think it’s really important to talk about two different types of injury to the rotator cuff. So, actually getting a tear in the rotator cuff, and it’s generally that one we talked about on the top. The cuff in the front and the cuff in the back can get torn but those are more unusual and really kind of a different situation. But for the top one, which is called the supraspinatus; that is actually torn sort of as a normal part of the aging process. So, if we looked at every 80 year old in the world, many, many, many of them would have a rotator cuff tear. But very, very, very few of them would actually have any pain or symptoms. So, we know we can do MRI scans on people with no symptoms at all and the older they are, the more likely they would be to have a hole in the rotator cuff.

Now how can you have a hole in your cuff and not have symptoms? It’s because what we talked about before. It’s the balance of the muscles around the shoulder. So, if the muscles in the front and the back are intact and they are strong and they are balancing out the other muscles around the shoulder; you can have a perfectly normal functioning shoulder, full range of motion and no pain even though there is that hole in the supraspinatus. So, we call that a tear, but it’s more of kind of a degenerative thing that can happen normally with time.

Now some people can have a tear for a very long time and have a normal functioning shoulder, but something will change, and it will set that off and they can start to have symptoms again. And they usually by retraining the muscles around the shoulder and that’s strengthening the rotator cuff but also very, very important, the muscles around the shoulder blade that control the position and the motion of the shoulder blade are tremendously important in this process and we’re learning more and more about that all the time. And we can generally get people back to a healthy normal functioning shoulder without much pain.

Now, let’s contrast that to somebody who had a completely normal rotator cuff and then they had an injury and that lead to a tear. Now in older people, that might not be that difficult to get a tear in the cuff because it may be already partially damaged or there may have already been a hole but not it grew in size. Let’s contrast that with a younger person. A younger person with a very healthy rotator cuff, it’s really hard to tear that. It can be done. High energy injury, a high fall, a motor vehicle accident, even a young person can get a rotator cuff tear and we treat that very differently. If it’s an acute injury; we would like to make the diagnosis and talk to that patient about a repair because the rate of healing is very high if we can do it early in that timeframe. And for a young person, a healed rotator cuff tear is highly desirable.

A group that we are particularly worried about is if we see people who are 40 or older and they have a dislocation, a shoulder dislocation; there’s a very high rate of rotator cuff tear in that population. Again, that is a young person they have very good capacity for healing and if we can fix that tear early; we have a good chance of getting it to heal and getting them their best shoulder moving forward. So, as people get older, it gets easier to tear it and again, it becomes more of just kind of the natural aging process.

The other thing that happens is as people get older, they lose the ability to heal that tear so, you’ve probably heard of people who were elderly and started having problems with their shoulder and they had a rotator cuff tear and they did the therapy and injections and we often refer to that as bursitis so people get injections for that and people can do really well with that and go along for quite some time and have a good functioning shoulder. But some people don’t respond to that.

In that situation, we often discuss rotator cuff repair surgery. The interesting thing about it is the older you are, the less likely it is to heal and so we do the rotator cuff repair surgery and it very often doesn’t heal. But yet 90% of people get good pain relief and get back to where they were and so it’s a very successful operation. I guess I went a little bit off topic there.

Host:  No, very good information to have, yeah. Yeah, so, it sounds like depending on age, several other factors, activity level, just lifestyle in general; you may have some people where over time, that rotator cuff just kind of wears. They may not even know that there’s an injury there. Other people could be in immediate reaction or response to an injury. What are some steps, I know there’s a full gamut of injury there, but what are some of the steps in identifying that you may have a rotator cuff injury?

Dr. Miller:  That’s a good question. Good question. So, if it’s that acute tear we were talking about, that’s a big injury. Most people are going to seek medical attention especially if they had a dislocation. A true dislocation is very hard to reduce that. Some people have been able to reduce a shoulder dislocation on their own, put it back in the socket. But in general, you are going to go to the emergency room and in that setting, probably some sort of imaging study will be ordered. MRI scan or an ultrasound or something like that. And so, then it would very quickly be brought to our attention and then we would talk to people about how they want to manage that.

For that atraumatic tear, so more of the degenerative tear; generally the symptoms are pain as you mentioned before, working overhead. So, when people have a symptomatic rotator cuff tear, they are often fine down below the level of their shoulder but as they work more away from their body and particularly going above the level of the shoulder into a cabinets or things like that and particularly people who are hammering above their head or those types of activities, they tend to have pain with that. The pain is sort of in the top and front area of the shoulder and that particular constellation of symptoms we refer to as impingement and also sometimes we will call that bursitis. That relates to that pinching that we talked about before when the cuff is not doing its job or the shoulder blade has an abnormal motion pattern that causes the ball to pinch against the bone in the top of the shoulder and maybe pinch that cuff. Rotator cuff tear in some people can actually cause pain in and of itself. Most people’s pain with a cuff tear is this impingement pain. But pain in the cuff itself is usually felt interestingly more in the arm, on the side of the arm. Now up around the shoulder, but it’s kind of a different kind of pain and those people maybe less likely to do well with conservative management but can still do well with conservative management. Those are probably the two biggest tip offs.

Host:  Okay. Good to know. So, now we know how to identify symptoms related to rotator cuff injury. Looking into treatment for that, potentially surgery. It sounds like surgery for a rotator cuff injury could be more advanced than other types of surgery because of the importance of mobility, complexity of the shoulder. Have there been any improvements in the technology, techniques for that type of surgery in recent years?

Dr. Miller:  There have. There’s been a lot of active research into this area both in trying to get the hole in the cuff to heal because obviously, if we are doing surgery to repair the tendon, we’d like that to heal. We know that people whose tendon does heal, there are small but measurable differences in strength and function. So, that’s obviously a benefit there but remember we talked about the patient who may have had a cuff tear for a long time and did fine and then something happened and now they become symptomatic. Sometimes that’s because the tear grew in size and the tear can actually grow so big that you can actually lose your ability to raise your arm. Not just because it hurts, so we could give you an injection, numb it up, you are not having pain, but you still can’t raise your arm; that’s a big problem.

So, if the tear heals, it’s less likely to grow and extend. So, a lot of research has been done looking at ways to make a repair stronger, more biologically active and increase healing rate. The other thing that has come up that’s been a big part of my practice in the last few years is that for people who don’t get better with physical therapy and injections and so now we’ve talked to them about surgery; sometimes the tear is so big that it actually can’t be repaired. At least on the top. The tear in the front, we are very successful at repairing that and that one actually heals quite well. The one in the back, we can usually repair, less good healing rate, but we can usually get that back. Sometimes the tear on the top is not repairable. Sometimes in that situation, and we talked about the people who the tear gets big enough, they lose their ability to raise their arm; sometimes we talked about how the rotator cuff holds the ball down, sometimes their ball will rise statically. So, we take an x-ray and the ball is not located in the socket anymore.

There is a newer technique that, well it’s actually a fairly old technique from Europe but it’s newer in the United States where there is a joint replacement called a ball and socket, reverse ball and socket joint replacement that has the ability to bring that head back down and now because the fulcrum is restored, the patient can raise their arm again. So, that’s been a huge development in the treatment of rotator cuff pathology that’s so severe that you lose your ability to raise your arm. And it can also be very helpful for pain. Of course, that replaces the entire joint and if you ever saw a picture of one, you would think twice about having it because the ball is on the socket and the socket is where the ball used to be, so it’s a big deal. And of course, in a lot of people, where they have a large rotator cuff; the ball is sneaking upwards, they’ve lost their ability to raise their arm, but the joint is still good.

So, in that patient population, you could argue that you may want to try to preserve the joint. Is there any way that you could restore the function and up until very recently, we did not have a technique to do that. Rotator cuff repair in that setting when the ball is up, does not work. In fact, most people actually get worse because of stiffness but in Japan, they were not allowed to use the reverse ball and socket and so a physician there named Teriso Mihata, developed this technique where he puts a graft in where the rotator cuff tear on the top was where the supraspinatus was. And he demonstrated that this graft has the ability to pull the ball back down in a very high percentage of cases and he was able to restore elevation.

And this is something that has very much caught on in this country now. Results haven’t been quite as good as the results in Japan, but it’s become a very important part of my practice and I’ve had very good results with it. So, that’s a very new thing I think that’s come along.

Host:  Interesting. Sounds like definitely a lot of options when it comes to the injury. Definitely depends on the type of injury that someone may have. Very cool, very interesting to hear that there’s a lot of newer research that’s come out and different techniques that can potentially help people where there was not a solution in the past. So, that’s very nice to hear. Looking at someone who, I mean if there is a rotator cuff injury, there may be a lot of choices; where should I have surgery. Should I try to go through physical therapy to heal that or making a lot of decisions there. Another thing to factor in is the recovery from a surgery which I’m sure there’s a lot that goes into that. So, can you talk to us a little bit about that, after someone has a type of rotator cuff surgery what can they expect through recovery? What’s that going to be like for someone?

Dr. Miller:  Yeah, that’s a great question. Because the recovery after rotator cuff is very extensive. And it’s fairly long and drawn out. And again, a lot of this is because our goal, if possible, is to get that cuff to heal. So, it turns out if you move the shoulder under your own power, you are firing the muscles and tendon units that we’ve repaired and that will lead to a failure of the repair. And so, in general, there is a period depending on the size of the tear, but maybe six to eight weeks of being in a sling and not moving the shoulder under the patient’s own power.

There’s a lot of debate in the field about whether the patient shouldn’t move at all versus some passive motion is okay. But in general, rehabilitation times are getting longer and longer and less and less active to leave time for healing because the healing really is an important part of this. Like I said whether it heals or not, pain relief is still – has the potential to be very good, probably in that 90% range. But we would like to get a healed tear if we could.

Once we go through this initial healing phase of let’s say six to eight weeks; at that point, then it’s either healed or it’s not healed and we have people start moving actively and we start going for full motion at that point and depending on the patient’s healing response; that can be very variable as to how long that takes for that to come back. Some people make a lot of scar and they get very stiff. And it can take a long time for that to loosen up. Now there’s a silver ling to that which is that most people who get profoundly stiff after cuff surgery, heal their cuff. But it’s painful and it’s very frustrating for people to go through like my shoulder is and moving and so I have a long conversation with people multiple usually about this beforehand because it’s not for everybody. And there are people who are very good surgical candidates in other words, that they’ve done all their rehab, they’ve done injections, they’ve tried everything that they can, still having symptoms and I think there’s a very good chance that they’d improve with surgery, but that rehab is just not something that they either can or are willing. Some people would just rather live with the pain than go through that.

But we’re looking at a good six months before it’s really kind of coming back and oftentimes a year. The stiffness problem we talked about at a year, if they are not moving at that point; they might need another surgery to take down scar tissue to get them mobile again, but they probably got a healed cuff in the long run. They might be better off.

Host:  Yeah, it’s definitely good to know what the expectations are ahead of time before going through that surgery and then feeling like things are getting worse before better. So, good to know there. Kind of backtracking a little bit, now that we know going through that surgery can or may be quite painful in the recovery after surgery; what are some things that people can do now even if their rotator cuff is not hurting, just proactive steps to prevent any sort of injury down the road?

Dr. Miller:  That’s a great question and it’s you know maybe not injury because that’s hard to sort of prevent but for just kind of shoulder health in general, a lot of it is postural. If people find that that shoulder is drooping and rolling forward; that can lead to this impingement process. There is a thought that the impingement actually wears on the cuff and creates the hole. So, if we could keep the shoulders back in a good position; it’s interesting because the cuff doesn’t get strengthened with our normal activities of daily living. And with the – even when people go to the gym and do weights; they don’t work on the little motors deep inside. And so the rehab that we put people in is very, very different.

My own personal bias is if people were doing that, they would probably be less likely to become symptomatic. But really no evidence for that.

Host:  Okay. Very interesting. Well Dr. Miller, you’ve shared a lot of valuable information today. I really appreciate you coming on the show. It’s been great.

Dr. Miller:  My pleasure, thanks.

Host:  Yeah, so thank you to our listeners as well for joining us today. I hope you found this information helpful if not for yourself, then perhaps for a family member or a friend that may be dealing with shoulder pain. If you have any questions or would like more information about Riverside Orthopedic Specialist, you can visit www.choosriversideortho.com or call 815-802-7090.