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Melanie Cole (Host): If you’ve ever gone to put your jacket on and there’s a searing pain in your shoulder, or maybe you’re a golfer and you’ve hit the ground just a few times and you really get that unending shoulder pain; it might be time to see an orthopedic surgeon to discuss some pain management. In this episode of Northfield Hospital and Clinics podcast series; we’re talking orthopedics and rotator cuff injuries. My guest, is Dr. Hans Bengston. He’s an orthopedic surgeon providing care at Northfield Hospital and Clinics. Dr. Bengston, people call it rotator cup, they don’t know what it is. Tell us what is involved in this complicated shoulder joint.

Hans Bengston, MD (Guest): You said it. I’ve heard so many different names for this particular injury. But nonetheless, the rotator cuff is a group of four muscles that make up the muscular support around the ball of the humerus. There’s one in front, one on top and two around the back. And they all converge to truly form a cuff of tissue around that humeral head. They help us rotate our arm, hence the name, the rotator cuff.

But perhaps one of the biggest jobs is actually to keep the humerus stable. When we try to lift our arm up, the big muscles, the deltoid muscle wants to just lift the humerus up kind of towards our head, if you will. But the rotator cuff helps hold that ball against the socket creating this stable base so that’s it’s a lever action to actually life our arm away from our body.

Super important for most any shoulder related activity, out away from our body, up overhead, and therefore, you can imagine how often it’s used throughout the day and people may experience pain.

Host: Well even that’s some of the cause of the pain isn’t it, it’s that it does the same motion like maybe a pitcher or somebody who golfs all the time. How are these injuries – what do you see most commonly as far as shoulder injuries?

Dr. Bengston: The rotator cuff being so frequently used with our shoulder do have a vast array of people who are at risk to injury. One thing we know is of course, like arthritis, the longer we live, the more stress that this is going to see and so those who age do have a higher risk for rotator cuff injuries or tears if you will. People who have repetitive overhead motion jobs. Maybe painters, carpenters, people who do athletic events like baseball or tennis, volleyball. All these sorts of things put a lot of stress on the shoulder and even if you are a weekend warrior, who just enjoys these activities occasionally, that can also put you at risk.

One of the hard parts about the rotator cuff is it’s vascular supply. It’s not a super robust vascular supply or blood supply if you will. So, when we get microscopic trauma; we don’t necessarily feel that right away. But when the body doesn’t have a great blood supply; it also doesn’t have a chance to heal and therefore these microscopic traumas add up over time and compound on one another. And eventually, leads to that straw that breaks the camel’s back.

And now you’ve got a painful shoulder. A subtle rotator cuff tear may become a larger rotator cuff tear.

Host: I get asked this question all the time Dr. Bengston. Do rotator cuff tears without surgery, with physical therapy, ice, bracing, whatever we are going to talk about; do they heal on their own? Does a tear heal or not really?

Dr. Bengston: You’re right. That is a very common question. The unique part about the rotator cuff is it does have some thickness to it. Maybe if we think about a sponge. If you were to make a hole all the way through the sponge; that would be a full thickness tear. The hard part about that when the rotator cuff has a full thickness tear; it tends to pull away from it’s normal attachment site because all of our muscles like a rubber band, un-stretch. And so if you cut one end of it or in this case, create a small tear; it pulls away from the attachment site. And it has no way to get back over there.

Those many times do need surgery. Now, there’s another subset of population who have a partial thickness tear where that sponge doesn’t have a hole all the way through it. but maybe the upper half of it has a defect. That would be a partial thickness tear. There are some fibers still intact, but some that are disrupted. Sometimes, those do have a chance to heal on their own. The unique part about both of these scenarios is both of them can advance or progress as time goes on. Maybe there are minor other injuries that occur and make it worse. Maybe it’s just life as it goes on makes it worse.

Those are people who may warrant eventual surgical intervention. But again, like most anything in our body; I think it’s always worthwhile giving it a try in that nonoperative route.

Host: So, let’s talk about some of those. Cortisone shots being something that I hear people talk about a lot. They say oh I’m going for another cortisone shot in my shoulder. How many can somebody get and what is that really doing for them?

Dr. Bengston: You know cortisone is the ultimate anti-inflammatory. It’s goal really is to calm inflammation. I don’t know that it has any healing factors or any way that it improves the body’s healing potential. But I do think it helps calm the symptoms. And that’s a very relevant thing for people because with shoulder problems and rotator cuff injuries in particular; they often describe that dull ache, dull deep ache or a sharp pain when they’re trying to hold that milk away from their body or reach for the cupboard over the head. Maybe it wakes them from sleep at night.

And obviously, we’ve all been there, right? When you’re sleep is disturbed, it is very difficult to enjoy life. That’s where the cortisone might come into play to help calm that inflammation. It just calms it down from a very potent localized direction.

Other things that people can try certainly do include ice, 20 minutes on, 20 minutes off, repeat. Ice is a very effective anti-inflammatory agent. Maybe medicines like ibuprofen, Naprosyn, Aleve. These are medicines that will calm inflammation as well. All these things in tandem can help calm those symptoms. Now certainly there are patients who do come back for a cortisone injection if they got relief that firs go around. But we usually like there to be multiple months say three or four months between injections. Because we recognize that if we do it too soon; it may actually have a small risk to weaken the collagen which is the building block of tendons. And that’s the last thing we want.

Host: What about nutrition? You know people hear about things like fish oil or taking some alternative things like chondroitin and – do any of these things have affect on whether or not we are feeling that pain?

Dr. Bengston: You know nutrition is so, so vital for anything that we have in our life, right? Our body is – that’s the fuel that gives us energy, it’s the fuel that helps us build from injured situations and the rotator cuff is no different. Now I don’t know that there’s anything specific that people can take or supplements that people can take that have proven to be healing factors for tendon injuries or rotator cuff injuries. But I would instead say it’s more general healthy diet. Getting those broad fruits and vegetables. Eating healthy grains if you are going to chose to do that. Proteins are very valuable. These are all things that are really important for any healing in our body.

A broad well-based nutrition, I think does have importance when it comes to general healing for tissues.

Host: So many rotator cuff injuries and shoulder injuries are from overuse, so much so that there’s now limits on pitching, for kids in certain sports. So, tell us about overuse and what we’re doing to our shoulders and your best advice for when you think it’s time for us to really have a discussion about more invasive procedures.

Dr. Bengston: Absolutely. Overuse is something that is very consistent with the rotator cuff injury, the rotator cuff tear. We mentioned before there might be certain jobs that put people at risk like carpentry or painting. But we also recognize that it could be a daily exercise habit. This can put people at risk to rotator cuff injuries.

It’s not to say that we should be doing overhead activity, but more it’s listening to the body. If there’s some pain, some sharp discomfort, maybe it’s waking you from sleep; these are times that we will want to back off. Give the body some time to heal. This also I think brings into play physical therapy. I am a strong believer in physical therapy for these injuries. And one of the reasons is our bodies respond to stress. If we do nothing; we get weak. Our muscles atrophy. And the tendons get weak too. But if we give it the proper stress, not too much, but the proper stress; it does have a chance, I think to truly put down new healthy tendon tissue to heal that tissue and give it a chance.

Now, that’s not say everybody who does therapy is going to have success. But I definitely think it’s a worthwhile try and something that we as surgeons like to try to start with. Even some full thickness rotator cuff tears do have a subset of patients who seem to be able to compensate and function very well in a nonoperative way. However, there are the patients who have tried the therapy, maybe they have tried an injection or medicines, they’ve modified their activity and they are still hurting. They are waking from sleep each night. They just can’t go about their daily life without really limited function. These are the people who are certainly worth a conversation for surgery. Rotator cuff surgery.

Host: Thank you so much Doctor, for joining us today and really giving us such a great education on the rotator cuff and shoulder injuries and when it’s time to see a physician. For more information please visit www.northfieldhospital.org. I’m Melanie Cole. Thanks for listening.