Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Scott Webb (Host): Rotator cuff injuries and tears are common, especially as we get older. And I'm joined today by Dr. Ryan Vellinga. He's an Orthopedic Surgeon at Skagit Regional Health, Smokey Point, specializing in sports medicine, arthroscopy and reconstructive surgery. And he's here today to tell us about the rotator cuff, signs and symptoms of injuries and what he can do to help. This is Be Well, the podcast from Skagit Regional Health. I'm Scott Webb. Doctor, it's so great to have you on, and I want to talk to you today about rotator cuffs. A lot of us think we know what they are. We think we know what they do. Some of us may have even had rotator cuff injuries, but it's great to have an expert on today. So as we get rolling here, maybe you can explain to the audience what exactly the rotator cuff is, what it does, and just kind of take us through some of the basics.

Ryan Vellinga, MD (Guest): So, the rotator cuff is a term used to describe a group of muscles in the shoulder. Now there are four muscles that make up your rotator cuff of your shoulder. And the muscles are attached to tendons and those tendons attach the muscle to the bone. So, these tendons on the top of your arm bone in your shoulder form a cuff of tissue that goes around the top of the arm bone.

So, that's why they call it the rotator cuff because it forms the cuff, but then these muscles help rotate your arm around in space. And that's where it gets the name rotator cuff for the shoulder.

Scott Webb (Host): Yeah, and it seems my experience or my knowledge of rotator cuff injuries is often through sports often baseball pitchers in particular. So good to know, just kind of set the stage here, exactly what that is up there, what it does. And if one of us were to tear our rotator cuff, what symptoms would we likely experience?

Dr. Vellinga: It can occur in two ways first of all. You can either have a traumatic tear. Like if you fell off of a ladder or something and landed on your shoulder, then you'd experience severe pain and inability to really raise your arm away from your body or overhead or up to shoulder height or something like that. But these tears can also be a slow degenerative tear that can develop over time from repetitive use. And either way though, when you start to get a tear, the pain will be in the shoulder kind of diffusely throughout the shoulder, or sometimes it can radiate from the shoulder down towards the elbow and the pain is typically worse when you're reaching your arm away from your body or reaching up to grab something from a shelf, sometimes reaching behind your back to tuck your shirt in or things like that. That's when people start to notice it. Pain with activities, and then it can progress to the point where they have pain even at rest and especially at night.

Scott Webb (Host): Yeah, so good to understand what we should be on the lookout for what we might be experiencing if we've had a tear. And I mentioned, you know, baseball players, and I'm sure they're not the only ones as you say, you could fall off a ladder and you could tear your rotator cuff, but who's generally most at risk for rotator cuff injuries?

Dr. Vellinga: So, typically, the most common patients with rotator cuff tears are individuals in their fifties to sixties. And these are the slow degenerative types of tears that develop. And that's the most common patient that we see with these. For, what we call the acute traumatic tears, the ones that happened suddenly from a fall or lifting something really heavy and you feel a pop in your shoulder and all of a sudden you can't raise your arm, those traumatic type tears, still more commonly occur in middle-aged individuals. But they can occur in younger patients as well, just given the traumatic nature, if the trauma is severe enough, they can have that happen and another circumstance where you can see these traumatic tears as if someone dislocates their shoulder. Now a younger person when they're in their teens or twenties, if they dislocate their shoulder, typically they tear the labrum in their shoulder. But once we're getting close to the age of 40 and above, anyone who dislocates their shoulder, the most commonly injured thing is actually the rotator cuff, which gets torn.

Scott Webb (Host): Yeah. Interesting you mentioned labrum and both my kids play sports. And so they've been through one's already through high school and a number of friends, boys and girls who play sports, had that exact injury that you're describing. But as you say, as you get older, then it often becomes the rotator cuff.

And it sounds to me, especially as you say when we're not talking about the acute tears or the traumatic tears, where it's a sort of a slow burn, a slow build over time as they, the tear begins to get worse over time. Is this something that people generally can live with? Do you find the patients have lived with some pain, some discomfort for a long period of time before they actually end up in your office?

Dr. Vellinga: Yes. I'd say usually at least a number of months if not several years. It's not uncommon for people to say their shoulder has hurt them off and on for years. And, you know, maybe they saw their primary care physician who gave him an injection or gave him some PT and it kind of got better for a while and then flared up again and got worse.

Yeah typically it's at least a matter of months. It's not something like you had no pain at all in your shoulder and then you didn't do anything, and you woke up with a horrible rotator cuff tear and pain all the time. That's not typically the case.

Scott Webb (Host): Yeah. You would assume that somebody with a traumatic tear, something acute, like that, would maybe go immediately to the emergency department or reach out to their primary to get a referral or something like that. But it does feel like one of those things where, you know, people probably just sort of live with it until they can't live with it anymore.

And then they come and seek your advice, your counsel, and along those lines, I'm guessing without even doing a physical exam, in most cases, most instances, I'm sure if someone just explains to you the pain that they're having or what they did that caused the pain, you probably can diagnose. But along those lines, how do you diagnose physically or otherwise a rotator cuff injury?

Dr. Vellinga: So the diagnosis comes by a combination of factors. It's first, very important to get a thorough history because typically patients can tell us what the problem is without us even touching them. If you just listen to them enough, they will tell you what the problem is when, what movements hurt it, when it hurts it and how it came about, those types of things really give you a clue.

And that will point you to what to look for on the physical exam. So, the next important piece is doing a good physical exam and if the history and symptoms correlate with what we pick up on doing a good physical exam, as we test each component of the rotator cuff, by then, we have a really good idea about what's going on in the shoulder.

And then we use imaging in the form of X-rays. And if we're worried about a significant tear of the rotator cuff, then we typically get an MRI. But so those x-rays and MRI can confirm our suspicion, that we built, or case, that we built, so to speak, based on the history and physical exam.

Scott Webb (Host): Yeah, that sounds right. That sounds pretty comprehensive. So we do the patient history, right? And then a physical exam and imaging to get a proper diagnosis. So, let's assume then that somebody has been diagnosed with a rotator cuff injury perhaps a tear. What are our options? Both surgical and non-surgical.

Dr. Vellinga: So, it's really important to determine once you have a problem with your rotator cuff, it's important for us to determine, is this a surgical problem or is it a nonsurgical problem? Once one of the rotator cuff tendons is completely detached from the bone, there is no amount of conservative treatments like injections or modifying your activities or physical therapy. Nothing is going to make that tendon grow legs and walk back over to the bone and reattach itself to the bone.

It becomes a very simple structural problem. Item A is no longer attached to item B and item A needs to be attached to item B, to give good function and not progress and get worse. So, that's what the MRI helps us decide. Okay. Is this a complete tear of one of the tendons where it's no longer attached to the bone and that makes it a surgical problem or is there just some inflammation of the tendon or let's say a partial thickness tear of the tendon where, you know, 80 plus percent could still be well attached, but you've got 10- 20% that's just kind of frayed and partially torn. Well, if there's still some attachment there, then you can try with greater effectiveness, the conservative treatments, like physical therapy, anti-inflammatory medications, injections perhaps various types that can be tried or just living with it. So, you don't really have to push yourself towards surgery if it's not a complete tear. Now in a circumstance where you have a partial tear and you try conservative treatments and they don't work, then sometimes we still choose to do surgery because you can still benefit from surgery to go in and repair, even a partial thickness rotator cuff, tendon tear.

But typically our conversation point goes straight to surgery if when we get that imaging, we see that there's complete detachment of one or more of the rotator cuff tendons away from the bone.

Scott Webb (Host): Yeah, I got it. And generally speaking, what's the recovery time? Let's assume that surgery is necessary either immediately or down the road after conservative options have been tried. Generally, what can folks expect in terms of the surgery and recovery time?

Dr. Vellinga: So, there are different approaches to how we recover from, but basically when we repair your rotator cuff tendon, we're going to use little anchors that go into the bone and we're going to pass sutures that are attached to those anchors and we're going to pass them through the torn end of the rotator cuff tendons.

So that as we tighten those sutures down, it's going to pull the tendon back over and compress it against the bone where it originally was. So, when we finish the surgery, right, and the first day, the only thing holding that tendon on the bone is the sutures and the anchors. But those are not strong enough to allow you to move your shoulder right away after surgery, without risk of the tendon tearing through the sutures.

So that's why this recovery is a little bit different than let's say even a shoulder replacement. Because you're trying to get that tendon to heal to the bone first, you have to give your body time to heal the tendon. And that typically takes between two to three months before the tendon has healed enough to the bone that now those repaired tendons can be used to move your arm around and do more aggressive exercises.

So for me, I typically let patients do mostly resting and healing for the first four to five weeks using a sling. And then after that, we start physical therapy to work on just stretching the scar tissue from the surgery out, stretching the shoulder for an additional six weeks while not really using those tendons to actively move the shoulder around.

And then once we're getting close to about the three-month mark when we have plenty of time for that tendon to heal onto the bone, that's when we can start with weighted activities and really work on more strengthening. But for most people, it's a multiple-month recovery. I'd say very few patients feel a hundred percent good to go at three months.

For most patients, I say somewhere between three and six months is when they start to feel a lot better and their stiffness is going away and their motion is coming back good. And their strength is starting to come back. But I tell every patient, for most shoulder surgeries, including rotator cuff repairs, it takes about six months to like that you had surgery and about a year to love that you had surgery. Not everyone follows that pattern, you know, there are outliers in both directions, but that's a general trend. Now you're not doing physical therapy for six months, typically. Most of my patients are done with physical therapy around four months.

It just takes your body time to completely heal and normalize again before the shoulder feels really great.

Scott Webb (Host): Yeah, I love that. And you have such a great way of explaining this stuff. Is it possible that people might think that they have arthritis, but it's actually a rotator cuff injury and either way is arthritis something that you treat as well?

Dr. Vellinga: Yes, arthritis in the shoulder is common and that's why as we're working up shoulder problems, we start with the history. Then we do a physical exam. And then the next most important step is to get X-rays, which is our best first test to determine if you have arthritis in your shoulder because if you have arthritis, it changes the treatment.

So, most rotator cuff surgery, if you're just repairing a rotator cuff, that's done arthroscopically, meaning through small incisions with a camera in your shoulder and using small instruments to do all the work inside, under video guidance. But you can't treat arthritis, especially end-stage arthritis, when we think about bone-on-bone arthritis, you can't fix that arthroscopically. And so if you have a rotator cuff problem, without arthritis, then we can treat it arthroscopically, minimally invasively to fix that. Whereas if you have arthritis in your shoulder and it is progressed arthritis, meaning your cartilage is so thin in your shoulder that you're almost bone on bone, then we're having a different discussion about surgical options. Because even if you have a rotator cuff tear and some arthritis, if you just fixed the rotator cuff tear, there may be a component of your pain that gets a little bit better. And your motion and strength may get a little bit better, but you're still going to have constant aches and soreness in your shoulder from arthritis.

Therefore, that's when we consider doing a shoulder replacement, just like we do a hip or a knee replacement, once you have advanced arthritis in your hip or knee, the same thing can be done for the shoulder. Interestingly, in the shoulder, when you have the combination of arthritis and a torn rotator cuff, historically we didn't have great treatment options for this.

And we would have to try to do a rotator cuff repair as part of the shoulder replacement. And if the rotator cuff healed, then you did great. But sometimes the rotator cuff wouldn't heal or it was just too torn. It had been torn for too long that there was no tendon to even heal. In those circumstances for a long time, we didn't have a good option in terms of shoulder replacement, because the standard shoulder replacement requires you to have an intact rotator cuff to function well.

But nowadays we have, what's called the reverse shoulder replacement, which by flipping around which side, the ball and the socket are on in your shoulder with the shoulder replacement implants we use, we don't need the rotator cuff for those implants to function. They will stay together well. And the other shoulder muscles like your deltoid, which is the large muscles that we get our vaccines and flu shots in and the latissimus in the back and the pec muscles in the front, those muscles are all that's needed to help keep a reverse shoulder replacement, stable and function pretty well. So it's a great treatment that we now use a lot in our country over the past, you know, 15 or so years.

And it's really solved that big problem of what do you do if you have, you know, a rotator cuff that is irreparable, doesn't work anymore and you have arthritis as well. We have a great treatment for it now.

Scott Webb (Host): This has been really educational. We've covered so much ground today. Really amazing. As we wrap up here, if someone's in a higher-risk demographic, or even if they're not, what tips do you have to help us all try to prevent rotator cuff injuries?

Dr. Vellinga: So the most important thing, especially as we age and get older, avoiding, you know, traumatic injuries, being very careful, you know, up on ladders and things where when our balance starts to change and we start to get more prone to falls. A trauma in the form of falls and things like that, although never intentioned can be the most catastrophic injuries that happen to us.

And so just being careful as we do that, maybe not being so eager to get up on the roof, to clean out the gutters, or whatever, putting ourselves in risky positions and for the rest of us, you know, it's a matter of staying active. There's a lot of good evidence to support that doing stretching frequently, doing basic shoulder exercises to keep those muscles as strong as they can be and healthy, is a great way to try to prevent it. Now we don't know if there's any one thing specifically, that you can do to guarantee that you're never going to get a rotator cuff tear, because like we said, most of these are kind of wear and tear injuries that occur over time and we still haven't figured out exactly why those even happen, so we don't know how to prevent them completely. But, for the most part, keeping your joints strong with regular exercise and stretching, keeping your joints mobile, keeping your muscles strong, I think across the board is helpful in preventing injuries and hopefully helping reduce the risk of even wear and tear injuries.

Scott Webb (Host): Doctor, this has been so great. So educational and a lot of fun. I'm sure listeners will really appreciate your expertise. So, thank you so much and you stay well.

Dr. Vellinga: I appreciate it very much. Thanks for your time.

Scott Webb (Host): For more information, go to SkagitRegionalHealth.org. And thanks for listening to Be Well, the podcast from Skagit Regional Health. If you enjoyed this podcast, please be sure to tell a friend and subscribe, rate and review this podcast on your favorite podcast app. I'm Scott Webb. Stay well, and we'll talk again next time.