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Melanie Cole (Host):  Rotator cuff injuries are most commonly linked with pitchers, but athletes aren’t the group of people most likely to suffer rotator cuff injuries. My guest today is Dr. Winston Gwathmey. He is a board certified orthopedic surgeon whose specialties include sports-related injuries to hip, shoulder, knee, foot, and ankle at the University of Virginia Health System. Welcome to the show, Dr. Gwathmey. Tell the listeners, what is the rotator cuff and what does it do?

Dr. Winston Gwathmey (Guest):  Thanks, Melanie. The shoulder is a very complex joint that has the highest range of motion in the joints of the body, and so intrinsically there’s very little bone stability. The bone socket of the shoulder joint isn’t really held together by much in the way of bones and ligaments. The rotator cuff is a complex group of muscles that wraps around the bone socket and holds the ball positioned within the socket so that you have the entire arc of motion without having any… or compromise the mechanics of the bone socket joint.

Melanie:  This is a very movable joint and also more complicated to treat if it’s injured, but easily injured. So, we hear a lot about rotator cuff injuries. How do they occur and what exactly is a rotator cuff tear? We hear so much about that, Dr. Gwathmey.

Dr. Gwathmey:  It’s actually a continuum of injuries. The rotator cuff is actually a pretty robust structure within the body, but as we sort of get older, a lot of things are breaking down the body and the rotator cuff, in particular, gets a lot of miles over the course of your lifetime. So, as people enter their 40s and 50s and 60s, just that motion that’s been going on there for so long can cause some breakdown when the pocket of the rotator cuff is… there’s a continuum and it starts with some tendonitis or some impingement type symptoms on the top of your shoulder, which is basically just shoulder pain, and as that tendon starts to become attenuated, it’s more prone to tearing. Sometimes, it might be something as little as overuse or sometimes it requires a more dramatic injury like a fall or something like that for that rotator cuff structure to be injured, but it can be quite debilitating when it does occur.

Melanie:  Tell us some of the symptoms because I know that when people say, “Oh, it hurts to roll over on my side at night or put a jacket on.” Tell people what they might experience that would send them to see you to look and see if it’s some rotator cuff problem.

Dr. Gwathmey:  Of course. I think most people, as they get older and they have shoulder pain they assume is the rotator cuff, it’s because it’s on the tip of their tongue whenever they’re thinking about shoulder pain. The most common symptoms of rotator cuff pathology is typically pain from the top or the front of the shoulder, worse with overhead activity like lifting a milk jug onto the top of the refrigerator or something like that or trying to put your clothes on. A lot of times, there’s pain at night. As the disease process progresses, sometimes it can also be associated with weakness in the same position for the same movement. Normally, you could easily put the milk jug on the top of the refrigerator and as the rotator cuff becomes more pathologic, it’s more difficult to do that. There’s pain as you try to lift your arm above the level of your shoulder.

Melanie:  If you’re diagnosed with having some sort of a rotator cuff injury, what treatments are available? Speak about non-surgical treatments first and then if it becomes bad enough, they have to deal with surgery.

Dr. Gwathmey:  I think the algorithm is there’s no question the first approach to a rotator cuff injury is going to be non-operative treatment. For the most part, there’s a lot of redundancy around the shoulder as far as function and even full-thickness rotator cuff tears can be treated non-operatively initially. There’s actually been studies showing in the average active population, almost a quarter of people in the age of 60 and almost half of people in the age of 80 actually have full-thickness rotator cuff tears and may not even know it. The initial goal of treatment is going to be to try and make that tear asymptomatic, which is simply possible with a good treatment algorithm. Normally, it requires some degree of either physical therapy exercises or activity modification to try to get the other muscles around the shoulder to activate and to fire so they can accommodate for the fact that one of the muscles up there has an injury. For the most part, the patient sees me with a rotator cuff type pain, which I try to get an idea of the degree of pathology and then normally, even if someone ends up having surgery, therapy or some sort of exercises are always helpful to optimize mechanics from the shoulder before we even get started on anything else.

Melanie:  What about cortisone shots? I know people, Dr. Gwathmey, that have had five, six, seven of them. How many can you get? And does a rotator cuff ever, if it’s a tear, does it ever really, truly go away on its own or that really just doesn’t happen?

Dr. Gwathmey:  Well, most of the natural history studies of rotator cuff pathology show that once a rotator cuff is torn, it will never actually heal. In fact, most of the time, it has some degree of progression. The speed of that progression is really what defines what treatments can end up being. Of course, I think it’s really helpful for a couple of reasons. One, I think in some of these acute inflammatory situations, you can actually take a tendon that is inflamed and swollen and causing more pinching of the shoulder. I use the analogy of the fat lip. When you have injury like that to your lip, you bite itover and over again until the swelling goes away. Sometimes with the rotator cuff, when you’re trying to get your arm above your head, the fact you’re sort of pinching that swollen tendon can propagate or perpetuate the symptoms. I do use cortisone periodically for people to try to see if I can get [rid of] that inflammation on the shoulder to get them a more pain-free range of motion so that they may make more progress with therapy and perhaps they can render this tear asymptomatic, which ultimately is the goal for all of these. To be honest, the tendon is not going to heal back down to the bone, but in a lot of cases, can actually make patients asymptomatic. I think  the goal is to get them back to what they wanted to do.

Melanie:  When does surgery come in to play?

Dr. Gwathmey:  I think when people have failed in all those concerted treatment strategies. If they’ve done therapy, they’ve done a cortisone shot or two, even taking anti-inflammatories, and really they’ll not be able to do what they want to do, pain at night, pain with routine activities, weakness so they can’t get their arm over their head, that’s really when we start talking about surgery for this. I always tell my patients this is not a very fun experience to go through, rotator cuff surgery. You’re going to be in a sling for six weeks, get the rehab pretty extensively for three to four months. That’s why we try to get people better without surgery, but if they do go to surgery, it’s fairly straightforward. We just take the tendon that’s torn and we repair it back down to the bone where it ripped from and once that process occurs, once the healing occurs, typically the symptoms get much better after surgery.

Melanie:  You mentioned that as we age, many people have rotator cuff injuries that they may not even be aware of. What about prevention and keeping that good strong shoulder?

Dr. Gwathmey:  Of course, prevention is the key to everything. As we get older, our bodies are going to have some degree of mileage that’s going to be put upon them. The goal of aging effectively is to optimize, stay healthy, exercise, those kinds of those things within the shoulder in particular. It’s always good to keep all the muscles on the shoulder fairly active and fairly strong so that you can tolerate this sort of wear-and-tear kind of stuff. A lot of people who are very firm, it just fit people who have rotator cuff tear they may or may not even know because there is so much extra muscle around the shoulder that can help out. It’s hard to prevent things that happen naturally with aging. I guess just trying to figure out how to live with the symptoms and how to improve the symptoms through exercise is probably the best thing.

Melanie:  Dr. Gwathmey, in just the last minute or two, why should patients come to UVA Orthopedics when they suffer a rotator cuff injury?

Dr. Gwathmey:  Well, we treat the entire spectrum of shoulder pathology. A lot of people come in with their primary care doctors if they have a rotator cuff problem, but really we’re pretty comfortable treating the entire spectrum of injury. Sometimes it’s not just the rotator cuff. There could be an element of biceps or labral pathology as well. There could be an element of arthritis as well. What we can do here – I have four partners and myself, all of them treat shoulder injuries – is we can take the entire natural history of their shoulder and provide basic care across all spectrums of shoulder injury, from shoulder instability, meaning shoulders that dislocate or shoulders that have arthritis or shoulders that need just some direction as far as why it hurts and how to make it feel better. Also, we have – the five of us – all of us do arthroscopic surgery for the shoulder to repair these things. It’s minimally invasive and we get people back to their activities as quickly as possible.

Melanie:  Thank you so much and for more information on UVA Orthopedics, you can go to uvahealth.com. That’s uvahealth.com. You’re listening to UVA Health Systems Radio. This is Melanie Cole. Thanks so much for listening and have a great day.