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Got Shoulder Problems? Let’s Talk about Rotator Cuff Tears
Your shoulder discomfort may be the result of a rotator cuff tear. Dr. Kevin Forsythe, orthopedic surgeon, discusses rotator cuff tears.
Featuring:
Kevin Forsythe, MD
Kevin Forsythe, MD is a board certified orthopedic surgeon who performs minimally invasive and arthroscopic procedures for shoulder, hip and knee disorders, including rotator cuff tears, dislocations, shoulder replacement, anterior hip replacement, hip arthroscopy, ACL reconstruction, meniscus repair, knee replacement, partial knee replacement, ultrasound guided injections, computer guided navigation shoulder and knee joint replacement, PRP injection. He completed his medical school and residency at Loyola University in Maywood, IL. Dr. Forsythe resides on the Central Coast with his wife and three children. Transcription:
Movember was born as an annual event where men grew mustaches in November to raise awareness of men’s health issues. In honor of Movember, Tenet Health Central Coast is focusing on men’s health topics.
Prakash Chandran (Host): This program is community service and is not intended to be a substitute for medical advice. Listeners having questions about their health should make an appointment to see their personal physician. Any opinions or statements made during the program are those of the individuals or physicians making the statements and are not the opinions or statements of the hospital.
Got shoulder problems? I know I do. Today, we’re talking about injuries in the shoulder, specifically rotator cuff tears. We’ll learn about what they are, how we get them, and most importantly, how they are best treated. Here to discuss is Dr. Kevin Forsythe, an orthopedic surgeon at Twin Cities Community Hospital. Dr. Forsythe, thank you so much for educating us today.
Kevin Forsythe, MD (Guest): Yeah, thank you for having me.
Host: Of course. So, I was recently tossing the football around with some friends and I noticed that afterwards I had a pain in my shoulder, especially when I tried to lift my arm. So, my first selfish question is to try to figure this out. Is this something trivial like muscle soreness or have I actually torn my rotator cuff?
Dr. Forsythe: It’s a good question. Sometimes I get that complaint a lot. It sometimes can be just simple bursitis which is inflammation in the shoulder and that can either die down on its own or with the help of physical therapy, a guided program with those guys or sometimes an injection if the pain is severe enough; we can get it to resolve and go away. If the pain is persistent and we do all these things and you are still having trouble, then sometimes we get some more advanced imaging of the shoulder to help tell us if there is a tear.
Host: And is a rotator cuff tear in terms of the pain level, is it much more painful than just the bruising that you are talking about?
Dr. Forsythe: It can be very similar. It’s sometimes difficult to differentiate because sometimes inflammation by itself can be quite severe and make you not even want to lift the arm at all which can mimic the symptoms of a torn rotator cuff. Now, the rotator cuff, what we’re talking about is basically four muscles that surround the ball and socket and they give you most of your power for your overhead activities from day to day. If they are inflamed or torn, they can cause a lot of pain, a lot of weakness, lose sleep, things like that.
Host: Yeah, I’ve definitely felt that before and I can understand what you are saying that it’s hard to distinguish the two because even the bruising can cause those symptoms as well. I’m curious as to how it happens. What is the most common thing or most common reason that you see for a rotator cuff tear?
Dr. Forsythe: Sure, yeah most of the time people tell me it just kind of crept up on them. Now, sometimes I get people who are digging the post holes for a fence or something really just strenuous and difficult on the shoulders and then bang within the next few days, they’ve got severe pain that won’t let up. But a lot of times, it’s sort of wear and tear type of things and then there’s sometimes some pain that’s been going on for a while and then all of the sudden some activity whether it’s trivial or not sets it off and makes it much worse. So, we don’t always have a single ah ha moment where we know that the rotator cuff tore, but it certainly becomes quite a problem when it does tear.
Host: So, let’s say I’m feeling that pain enough to the point where I want to bring myself in to seek treatment. What does that look like? What kind of options would be available to me?
Dr. Forsythe: Well it depends on what your story is. Everybody has got a unique story and that’s an important part of it. Aside from the physical examination in the office obviously and usually we start with a basic x-ray that people think sometimes is not very useful because it’s not as fancy as an MRI, but it gives us a lot of information about calcium deposits that sometimes can cause inflammation or bursitis in the shoulder around those rotator cuff muscles or if there’s arthritis in the shoulder, that might be another pain generator that we need to know about early on.
But in general, it would be even without the MRI, if I have enough information to show me that there’s a lot of inflammation, then we can get physical therapy going and it’s usually about a four to six week course of that before we decide to do anything more aggressive.
Host: I see. So, it sounds like it’s a case by case basis. The first thing that you try to recommend is physical therapy regiment for about four to six weeks. And what does that look like? Is it just exercises, overhead exercises that you slowly work up to?
Dr. Forsythe: Yeah. So, it’s typically two or three times a week. We find a place that’s close to your house and make it as convenient as possible. And then they do a number of types of so-called cuff-strengthening, scapular stabilization, sometimes there’s issues with the wing bone not moving correctly and that can lead to issues with the shoulder. And balancing the four muscles, those four rotator cuff muscles a lot of times are out of balance with our daily life. And so, getting them back into balance can take stress and pain away from the shoulder.
Now some people sometimes will come in with an MRI already done and it shows there’s a gradation or a number of different ways that the rotator cuff can have a tear. Some are severe and some are not so bad. If it’s a partial or minimal tear of the tendon, so it’s not completely detached from bone; then a lot of times physical therapy can settle that down. If I do about 200 shoulder arthroscopies in a year; maybe 20 or 30 are for the partial tear. So, it’s much less common that that ends up being a surgical repair type of issue.
Host: So, let’s talk about the surgical repair or the rotator cuff tears that are severe enough to warrant them. Talk a little bit about the surgical process and the recovery time.
Dr. Forsythe: So, the surgery in my hands, these are all arthroscopic procedures which means they are done with little poke holes around the shoulder, four of them, sometimes five of them depending on how much work I have to do. And someone would be asleep for about 45 minutes to an hour. I would go in there with the cameras and the tools and reattach the tendon to bone with these stiches we have now that can actually be locked into the bone to hold the tendon back to where it pulled away from.
Ideally, you go home about an hour after the procedure. You are wearing this sort of fancy sling for about four weeks for the average person, which allows you to protect the repair while it’s healing, but then you can do waist level things during that first month. So, I don’t let people do anything overhead while that tendon is healing back down to the bone.
After that first month, the brace goes away, and we start gradual strengthening and overhead work with a physical therapist. Average person at eight to ten weeks after surgery is starting to lift overhead, grab things out of shelves and cabinets, but it feels weak pretty quickly. It’s more like three or four months where you start feeling a little bit more normal with your endurance and your activity level. But you see things improve for up to a year after the repairs are done.
Host: One of the things that I was wondering is rotator cuff tears in the world of sports. Because I know that for example for a quarterback, if something severe happens and they do need surgery; sometimes it feels like they are able to recover much quicker than the normal everyday person. And I’m wondering if there’s ever cases where they start playing before they should?
Dr. Forsythe: Yeah, there definitely are situations like that and we find both with rotator cuff, shoulder issues, some of the knee issues like ACLs, various repairs and reconstructions that probably less people go back to their previous level of sport than we anticipated for elite level athletes. But most of us who are the weekend warriors, rotator cuff repairs tend to do quite well. We do see healing be a little bit more difficult after the age of 70 when you do these repairs. But it still has a good chance of healing even with advanced age.
So, there’s also the other factor coming into play, kind of one of the more exciting things is with partial cuff tears, if physical therapy has failed; there’s now an option like PRP which is a platelet rich plasma where in the office we can draw blood, spin it down in a centrifuge and the top layer after you pull it out of the centrifuge is full of the growth factors and healing factors in your bloodstream that you isolate out and inject that into the torn tendon to see if you can get it to heal that way. And I have seen some really promising results with that. So, that’s another way we can try to avoid surgery and get people back to activities.
Host: Yeah, that sounds extremely advanced. I actually wanted to ask about topical treatments because whenever I would get an injury like that; my dad would always say to put on Tiger Balm or Ben Gay over it, to heal. So, maybe talk a little bit about the effectiveness of these topical treatments.
Dr. Forsythe: Yeah, I find topicals to be a nice adjunct especially with people who have trouble tolerating regular anti-inflammatories which are your Aleve, naproxen, ibuprofen and Motrin. You have a wide array now of these topicals that you can use. One of the more commonly prescribed ones is Voltaren Gel, although a lot of insurances have trouble covering that. There’s also simpler things like capsaicin cream, or arnica gel which I find to be helpful and these are more natural sort of plant-based anti-inflammatories. It sounds a little hokey to put a gel on the skin over the injured area to some people. But I do find that it can be quite helpful, and we don’t see as much systemic or body absorption of the – that we would have with your pill anti-inflammatories that could cause problems with your stomach and kidneys. I think those are a nice alternative.
Host: Yeah, thanks for that and Dad, if you’re listening, I guess you were right. Those things do help. The final thing I wanted to ask you is, is there anything that people can do to prevent this type of injury? Is it mobility exercises? What do you recommend?
Dr. Forsythe: Yeah. So, one of the simplest things you can do is just get onto YouTube and put in rotator cuff strengthening exercises. And with simply one of those resistance bands that you can get at a local sports store; you can at home, keep a balance of those four rotator cuff muscles that surround the ball and socket. That’s very important because we tend to overuse one side or the other of the shoulder muscles, create the imbalance which we think then leads to problems down the road. So, those simple sort of resistance exercises with just a little rubber band, it doesn’t have to be a fancy thing at the gym; can really help out and in general, I find people stay out of trouble if they keep heavy things close to their body when they are lifting them. Don’t reach out for that thing that’s heavy across the way, just take the time to walk over, get closer to it and put yourself in a position of advantage to pick things up and make it easier on those cuff muscles.
Host: Great advice. I really want to thank you for educating us today Dr. Forsythe, is there anything else you want to share with our audience before we sign off today?
Dr. Forsythe: No, I think we covered most of the important parts of the issue and I hope people get a little bit of help out of this and get some pain improved.
Host: Yeah, absolutely will. So, for a referral to a board-certified physician, please call the Sierra Vista Regional Medical Center and Twin Cities Community Hospital Physician Referral Line at 866-966-3680. My guest today has been Dr. Kevin Forsythe. I’m Prakash Chandran. Thank you so much for listening.
Movember was born as an annual event where men grew mustaches in November to raise awareness of men’s health issues. In honor of Movember, Tenet Health Central Coast is focusing on men’s health topics.
Prakash Chandran (Host): This program is community service and is not intended to be a substitute for medical advice. Listeners having questions about their health should make an appointment to see their personal physician. Any opinions or statements made during the program are those of the individuals or physicians making the statements and are not the opinions or statements of the hospital.
Got shoulder problems? I know I do. Today, we’re talking about injuries in the shoulder, specifically rotator cuff tears. We’ll learn about what they are, how we get them, and most importantly, how they are best treated. Here to discuss is Dr. Kevin Forsythe, an orthopedic surgeon at Twin Cities Community Hospital. Dr. Forsythe, thank you so much for educating us today.
Kevin Forsythe, MD (Guest): Yeah, thank you for having me.
Host: Of course. So, I was recently tossing the football around with some friends and I noticed that afterwards I had a pain in my shoulder, especially when I tried to lift my arm. So, my first selfish question is to try to figure this out. Is this something trivial like muscle soreness or have I actually torn my rotator cuff?
Dr. Forsythe: It’s a good question. Sometimes I get that complaint a lot. It sometimes can be just simple bursitis which is inflammation in the shoulder and that can either die down on its own or with the help of physical therapy, a guided program with those guys or sometimes an injection if the pain is severe enough; we can get it to resolve and go away. If the pain is persistent and we do all these things and you are still having trouble, then sometimes we get some more advanced imaging of the shoulder to help tell us if there is a tear.
Host: And is a rotator cuff tear in terms of the pain level, is it much more painful than just the bruising that you are talking about?
Dr. Forsythe: It can be very similar. It’s sometimes difficult to differentiate because sometimes inflammation by itself can be quite severe and make you not even want to lift the arm at all which can mimic the symptoms of a torn rotator cuff. Now, the rotator cuff, what we’re talking about is basically four muscles that surround the ball and socket and they give you most of your power for your overhead activities from day to day. If they are inflamed or torn, they can cause a lot of pain, a lot of weakness, lose sleep, things like that.
Host: Yeah, I’ve definitely felt that before and I can understand what you are saying that it’s hard to distinguish the two because even the bruising can cause those symptoms as well. I’m curious as to how it happens. What is the most common thing or most common reason that you see for a rotator cuff tear?
Dr. Forsythe: Sure, yeah most of the time people tell me it just kind of crept up on them. Now, sometimes I get people who are digging the post holes for a fence or something really just strenuous and difficult on the shoulders and then bang within the next few days, they’ve got severe pain that won’t let up. But a lot of times, it’s sort of wear and tear type of things and then there’s sometimes some pain that’s been going on for a while and then all of the sudden some activity whether it’s trivial or not sets it off and makes it much worse. So, we don’t always have a single ah ha moment where we know that the rotator cuff tore, but it certainly becomes quite a problem when it does tear.
Host: So, let’s say I’m feeling that pain enough to the point where I want to bring myself in to seek treatment. What does that look like? What kind of options would be available to me?
Dr. Forsythe: Well it depends on what your story is. Everybody has got a unique story and that’s an important part of it. Aside from the physical examination in the office obviously and usually we start with a basic x-ray that people think sometimes is not very useful because it’s not as fancy as an MRI, but it gives us a lot of information about calcium deposits that sometimes can cause inflammation or bursitis in the shoulder around those rotator cuff muscles or if there’s arthritis in the shoulder, that might be another pain generator that we need to know about early on.
But in general, it would be even without the MRI, if I have enough information to show me that there’s a lot of inflammation, then we can get physical therapy going and it’s usually about a four to six week course of that before we decide to do anything more aggressive.
Host: I see. So, it sounds like it’s a case by case basis. The first thing that you try to recommend is physical therapy regiment for about four to six weeks. And what does that look like? Is it just exercises, overhead exercises that you slowly work up to?
Dr. Forsythe: Yeah. So, it’s typically two or three times a week. We find a place that’s close to your house and make it as convenient as possible. And then they do a number of types of so-called cuff-strengthening, scapular stabilization, sometimes there’s issues with the wing bone not moving correctly and that can lead to issues with the shoulder. And balancing the four muscles, those four rotator cuff muscles a lot of times are out of balance with our daily life. And so, getting them back into balance can take stress and pain away from the shoulder.
Now some people sometimes will come in with an MRI already done and it shows there’s a gradation or a number of different ways that the rotator cuff can have a tear. Some are severe and some are not so bad. If it’s a partial or minimal tear of the tendon, so it’s not completely detached from bone; then a lot of times physical therapy can settle that down. If I do about 200 shoulder arthroscopies in a year; maybe 20 or 30 are for the partial tear. So, it’s much less common that that ends up being a surgical repair type of issue.
Host: So, let’s talk about the surgical repair or the rotator cuff tears that are severe enough to warrant them. Talk a little bit about the surgical process and the recovery time.
Dr. Forsythe: So, the surgery in my hands, these are all arthroscopic procedures which means they are done with little poke holes around the shoulder, four of them, sometimes five of them depending on how much work I have to do. And someone would be asleep for about 45 minutes to an hour. I would go in there with the cameras and the tools and reattach the tendon to bone with these stiches we have now that can actually be locked into the bone to hold the tendon back to where it pulled away from.
Ideally, you go home about an hour after the procedure. You are wearing this sort of fancy sling for about four weeks for the average person, which allows you to protect the repair while it’s healing, but then you can do waist level things during that first month. So, I don’t let people do anything overhead while that tendon is healing back down to the bone.
After that first month, the brace goes away, and we start gradual strengthening and overhead work with a physical therapist. Average person at eight to ten weeks after surgery is starting to lift overhead, grab things out of shelves and cabinets, but it feels weak pretty quickly. It’s more like three or four months where you start feeling a little bit more normal with your endurance and your activity level. But you see things improve for up to a year after the repairs are done.
Host: One of the things that I was wondering is rotator cuff tears in the world of sports. Because I know that for example for a quarterback, if something severe happens and they do need surgery; sometimes it feels like they are able to recover much quicker than the normal everyday person. And I’m wondering if there’s ever cases where they start playing before they should?
Dr. Forsythe: Yeah, there definitely are situations like that and we find both with rotator cuff, shoulder issues, some of the knee issues like ACLs, various repairs and reconstructions that probably less people go back to their previous level of sport than we anticipated for elite level athletes. But most of us who are the weekend warriors, rotator cuff repairs tend to do quite well. We do see healing be a little bit more difficult after the age of 70 when you do these repairs. But it still has a good chance of healing even with advanced age.
So, there’s also the other factor coming into play, kind of one of the more exciting things is with partial cuff tears, if physical therapy has failed; there’s now an option like PRP which is a platelet rich plasma where in the office we can draw blood, spin it down in a centrifuge and the top layer after you pull it out of the centrifuge is full of the growth factors and healing factors in your bloodstream that you isolate out and inject that into the torn tendon to see if you can get it to heal that way. And I have seen some really promising results with that. So, that’s another way we can try to avoid surgery and get people back to activities.
Host: Yeah, that sounds extremely advanced. I actually wanted to ask about topical treatments because whenever I would get an injury like that; my dad would always say to put on Tiger Balm or Ben Gay over it, to heal. So, maybe talk a little bit about the effectiveness of these topical treatments.
Dr. Forsythe: Yeah, I find topicals to be a nice adjunct especially with people who have trouble tolerating regular anti-inflammatories which are your Aleve, naproxen, ibuprofen and Motrin. You have a wide array now of these topicals that you can use. One of the more commonly prescribed ones is Voltaren Gel, although a lot of insurances have trouble covering that. There’s also simpler things like capsaicin cream, or arnica gel which I find to be helpful and these are more natural sort of plant-based anti-inflammatories. It sounds a little hokey to put a gel on the skin over the injured area to some people. But I do find that it can be quite helpful, and we don’t see as much systemic or body absorption of the – that we would have with your pill anti-inflammatories that could cause problems with your stomach and kidneys. I think those are a nice alternative.
Host: Yeah, thanks for that and Dad, if you’re listening, I guess you were right. Those things do help. The final thing I wanted to ask you is, is there anything that people can do to prevent this type of injury? Is it mobility exercises? What do you recommend?
Dr. Forsythe: Yeah. So, one of the simplest things you can do is just get onto YouTube and put in rotator cuff strengthening exercises. And with simply one of those resistance bands that you can get at a local sports store; you can at home, keep a balance of those four rotator cuff muscles that surround the ball and socket. That’s very important because we tend to overuse one side or the other of the shoulder muscles, create the imbalance which we think then leads to problems down the road. So, those simple sort of resistance exercises with just a little rubber band, it doesn’t have to be a fancy thing at the gym; can really help out and in general, I find people stay out of trouble if they keep heavy things close to their body when they are lifting them. Don’t reach out for that thing that’s heavy across the way, just take the time to walk over, get closer to it and put yourself in a position of advantage to pick things up and make it easier on those cuff muscles.
Host: Great advice. I really want to thank you for educating us today Dr. Forsythe, is there anything else you want to share with our audience before we sign off today?
Dr. Forsythe: No, I think we covered most of the important parts of the issue and I hope people get a little bit of help out of this and get some pain improved.
Host: Yeah, absolutely will. So, for a referral to a board-certified physician, please call the Sierra Vista Regional Medical Center and Twin Cities Community Hospital Physician Referral Line at 866-966-3680. My guest today has been Dr. Kevin Forsythe. I’m Prakash Chandran. Thank you so much for listening.