Scott Webb (Host): A healthy rotator cuff on our shoulders is essential to normal and pain-free use of our shoulders and arms. And in this episode, Dr. Robert Davis, orthopedic surgeon with SolutionHealth, discusses rotator cuff tears, the latest treatment options, including surgery, and some injury prevention tips. 

This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb.
Dr. Davis, thanks so much for your time today. We're going to talk about common shoulder injuries and surgeries, and I know probably at the top of that list is rotator cuff injuries. So, let's just start here, a little foundational question. What is the rotator cuff? Why do we need it? What does it do?

 Dr. Robert Davis: So, the rotator cuff is a series of four muscles that originate off the shoulder blade and then attach around the ball of the upper arm bone called the humerus and specifically what's called the humeral head. That's the ball part of the shoulder joint. And these four muscles are deep in the shoulder and they assist the shoulder in rotating inward and outward and also assist in lifting the arm above the head, along with some of the other muscles around the shoulder.

Host: Yeah. So, it's not a metaphor. The rotator part of that rotator cuff, it really does help it to rotate. And good to understand sort of how the shoulder works. And I've heard about these injuries, be it sports and otherwise, anecdotal, and otherwise. So, what does it mean when someone has a rotator cuff tear?

 Dr. Robert Davis: So, all muscles attached to bones with tendons. And the rotator cuff muscles, just like any other muscle, has a tendon that attaches to the bone of the upper arm. So, a rotator cuff tear is very simply when that tendon tears away or becomes detached from the bone. And sometimes the tendon becomes completely detached, sometimes it's partially detached. But either way, when it becomes detached, it doesn't work properly. So, if it's completely detached, then that muscle obviously then cannot perform its function. It cannot pull the arm or lift the arm the way it normally should. And frequently, in addition to causing weakness because the muscle's no longer attached, it will also cause pain.

Host: Yeah. And are these tears typically the result of some sort of traumatic acute injury? Is it something that happens over time? It starts out as a little tear and then it just gets bigger and bigger through use and overuse? Take us through that, like basically, who gets this injury and how?

Dr. Robert Davis: So, the vast majority of rotator cuff tears are really degenerative problems, so problems of getting older. And the tendon wears out as we get older. It can start to fray and weaken. And then, it can simply tear on its own, just from becoming weaker, like an old frayed rope, or it can be a little weaker than normal and then someone has a fall. They could fall on their arm or on their shoulder off a step stool or a ladder or skiing or any number of ways, obviously. And then, that can sort of finish off the tendon, meaning tear it off the bone the rest of the way. Many times, the tears are progressive, meaning they'll start out small and then gradually worsen over some period of time. Sometimes over a long period of time, sometimes over a shorter period of time. A lot of people hear about rotator cuff tears with, you know, baseball pitchers, and that's really a special subset. For the vast majority of people, younger people, rotator cuff tears are not an issue. It is rare to see outside of a high-level athlete, it's rare to see a rotator cuff tear in somebody in their 20s and 30s unless they had a major injury. But by far and away, most rotator cuff tears are problems for people in their 50s, 60s, and older.

 Host: Yeah, I see what you mean. Unless you're in the business of throwing 95-mile-an-hour hitters, you're probably not going to get that type of tear. It's sort of a use and abuse and over time and just sort of age-related. So, let's talk then about treatment options. Are there some non-surgical things you do first, physical therapy, injections, that kind of thing? And then, ultimately, what leads to surgery?

 Dr. Robert Davis: So, the rotator cuff tendons do not generally have very good blood supply, and blood supply is critical for anything to heal. In addition, once they tear, the muscle itself is effectively pulling the tendon away from the bone. So, the tendon will never just go back and sit down against the bone and heal on its own.

 Host: Yeah, it's not magic. It doesn't just heal itself, right?

 Dr. Robert Davis: Right. Because, again, the muscle is always pulling it away from where it needs to be. And sometimes these tears, the tendon is close to where you need to reattach it to the bone. But larger tears, particularly ones that have been present for a long time, the tendon can pull away from where it needs to be several centimeters. And for us, several centimeters is a pretty long distance. So, in order to repair that tendon, you have to get that tendon back to where it tore off the bone. Some smaller tears, very small tears, or what we call partial tears, may be able to be treated non-operatively with physical therapy, cortisone injections, et cetera. But larger tears generally will not be successfully treated non-operatively depending on the patient's age. That is to say that if you're 50 and you have an obvious rotator cuff tear and we know you could live another 30 or 35 years, we know that tear will get worse over time without question.

 And if you're having pain and you can't function and you're 50, you're not going to tolerate that very well. On the other hand, if you're 85 and you have a tear and your demands for function of your arm are less than a younger patient, or maybe you have a lot of medical problems, we may be less aggressive about surgical treatment for that kind of rotator cuff tear compared to someone who's younger.

Host: So, let's assume then that someone is a good candidate for the surgery. They have the type of tear, the big enough tear and their age, and all of it makes sense. I don't want you to necessarily, you know, go into too much sort of inside baseball, if you will. But how do you do that? How do you repair the tendon, if you could just maybe take us in the OR just a little bit? 

Dr. Robert Davis: So, again, the goal is to reattach the tendon to the bone, ideally where the tendon was originally attached to the bone. So, surgery involves usually looking in the shoulder with a camera called arthroscopy or a scope, and we're going to inspect the entire shoulder, look for any other problems and look for that rotator cuff tear. And then, we are going to proceed with trying to reattach that tendon to the bone. And the way that is done is we sew the tendon back to the bone. We put in these little devices in the bone that we call suture anchors, which are if you think of a wall anchor, it's a little device that goes in the bone that then anchors stitches or sutures into the bone, so we have something to sew to. And then, we pass those sutures through the rotator cuff tendon and tie the sutures down, and that tacks the tendon back down to the bone in order for it to heal.

 Host: That's very cool. Great job explaining that without any sort of visuals, like you might in the office. You know, I've heard, doctor, that the recovery from this surgery, right? So, those that are healthy enough to have it and make sense to have it, even then, the recovery can be a long process, could take maybe up to a full year for them to get back to normal. So, maybe you can take us through that. What's the recovery like? Why does it take so long? What's involved, and so on?

Dr. Robert Davis: So, you are correct that full recovery or seeing the full benefit from the surgery can take up to a year. But certainly, you know, most people are not incapacitated for anywhere near that long. Having said that, it is a long and, I tell patients, it's an inconvenient recovery. And what I mean by that is usually it's outpatient surgery, so you don't have to stay in the hospital, but you're going to be in a sling and you're not going to be able to use the arm normally for at least the first six weeks. That first six weeks is critical to get the tendon to start to heal back to the bone. And if you start using your arm too quickly, the sutures that we used to repair the tendon to the bone will weaken or loosen and the tendon will pull away from the bone a little bit. And if a gap develops between the tendon and the bone, the tendon will not heal properly.

 So, that first six weeks is really what we're trying to do is protect the repair, not do anything to stress the repair, and allow that initial healing of the tendon to the bone. It is common for people to start moving their shoulder with the assistance of a therapist during that time, doing what we call passive motion, meaning the therapist is moving the arm, but the patient's not using their own muscle power to use the arm because using your muscles will then pull on the repair site.

So, the first six weeks we want to protect the repair and get that tendon to heal. Then usually after six weeks, the sling is discontinued, and the patient can start trying to lift the arm on their own. They still have stiffness in the shoulder that they're working through with the therapist. But life gets a lot better after that first six weeks. You can start using the arm more normally, nothing strenuous, but for normal everyday activities. And then usually, around the three-month mark is when we would start working on strengthening. So again, we don't want to overstress the rotator cuff repair early. So, we wait until about three months to do any actual resistance or strengthening exercises with what are called TheraBands, which are these colored, stretchy rubber bands, or even maybe real light dumbbells, one pound, two pounds. And then, beyond the three-month mark, maybe still working on regaining some motion, working on strengthening, but by that point, everyday life is pretty much back to normal for most patients. If someone has a physically demanding job, like a construction worker, then their ability to get back to work is certainly much different than someone who has an office job. So, occupation can make a big difference, obviously, in a patient's ability to return to work.

 Host: Yeah. And if they're, let's say, good patients, especially for that first six weeks, is it the expectation, is it your expectation that most folks will be able to return to whatever they were doing before, or whatever that is, golf, skiing, pickleball, which seems so popular? Is full recovery expected in most cases?

 Dr. Robert Davis: So, there are certainly a lot of factors that go into that assessment. Some patients have very large tears. If that tear is retracted, like we talked about, it's a long distance from the bone. It can be more difficult to repair. The outcome may not be, you know, a hundred percent. And again, if you are talking about someone who has a desk job, obviously, they're going to be putting a lot lower demand on their shoulder, and it's going to be easier for them than for that construction worker.

I would say for the vast majority of the patients, they do very well. They might be 80 to 90%, maybe not 100%. Some patients are 100 percent. But certainly, those that put higher demand on their shoulder may notice deficits compared to what they had before they had a shoulder problem.

 Host: And that seems key, right? Because if you say that, "Yeah, we get you to about 80, 90% of what you were before you were injured, but without the surgery, you wouldn't be anywhere near 80 to 90%." And as you say, especially for folks who might have construction jobs and put high demands on that shoulder, 80 to 90% sounds pretty good.

 This has been really educational today. I'm always fascinated to learn from experts and I definitely have done that today. Just give you a chance here at the end, when folks are trying to think about or going through the process of choosing an orthopedic surgeon so they know they have a bad enough tear and they need to have the surgery, what would be your recommendations in terms of sort of vetting or interviewing surgeons and choosing the right one?

 Dr. Robert Davis: Mostly, it's just about finding a surgeon who treats shoulder problems routinely and takes care of rotator cuff tears on a regular basis. And then beyond that, some of it is a personal fit when you see the surgeon and you seem like you have a good rapport with them. Obviously, you need to be able to trust the surgeon that you feel like they're going to do the best job they can for you. So, that's important as well.

Host: Yeah, exactly. You want an expert, someone who does this routinely, who has good results, as you say, fit, trust, all that good stuff. So, thank you so much today, doctor. You stay well.

 Dr. Robert Davis: Okay. Thanks. You too, Scott.

 Host: And for more information, go to snhhealth.org/ortho. And if you enjoyed this podcast, please be sure to tell a friend and share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.