Alyne: As the baby boomers hit their seventies, one thing is certain, their injuries rise. Our topic today is an increasingly common problem, a rotator cuff issue. This can cause everything from a dull ache in your shoulder to arm weakness and difficulty combing your hair.

Dr. Jonathan Chappell is an orthopedic surgeon and a sports medicine specialist at Wake Orthopaedics. He joins me to tell us how to get relief. This is WakeMed Voices, a podcast by WakeMed Health and Hospitals. I'm Alyne Ellis. Welcome, Dr. Chappell.

Dr. Chappell: Pleasure to be here.

Alyne: So let's start with a description of the rotator cuff and how it works.

Dr. Chappell: So the rotator cuff is a structure that's made of four muscles that surround the ball of the ball and socket joint of the shoulder. One of the rotator cuff muscles in the front is called the subscapularis, which is a tendon that is very rarely injured. The most common thing we see are the rotator cuff muscles on the top called the supraspinatus and infraspinatus behind that, and then a really small muscle in the very back called the teres minor. And these muscles work in conjunction with the other muscles around the shoulder to help you bring your arm up into the air and do overhead activities, reach things on a shelf and other daily activities.

Alyne: So what kind of issues do people have as they age with the rotator cuff?

Dr. Chappell: We know that rotator cuff injuries and specifically tears of the rotator cuff are common and often associated with age. We find folks who in their sixties and seventies will start to have small partial tears or fraying of the rotator cuff, and those will often go on to complete tears within two or three years.

And once you reach a point, you have a complete tear of the rotator cuff, the majority of those people start having symptoms. And that's usually pain with reaching for something on a shelf or other overhead activities or lifting things. It often can start very simply as just pain when doing things around the house, like things overhead and putting things on a shelf or doing yard work or gardening. And sometimes we see it when people have a traumatic event, like a fall or other injury,

Alyne: And it also can be caused not just by lifting and injuring yourself that way, but also by arthritis or even family history.

Dr. Chappell: Correct. Absolutely. So the rotator cuff itself plays an important role in keeping everything, the ball and socket, in appropriate position. So as you start to develop these tears, you can then develop arthritis as a result of rotator cuff tears.

So when we talk about arthritis of the shoulder, there's two types of arthritis. There's the traditional arthritis that people think about when they think about knee arthritis and hip arthritis. And that's the standard arthritis associated with wear and tear and age. And then there's a whole 'nother set, another type of arthritis that's associated with people who have either torn rotator cuff or rotator cuff that's just not working the way that it should. And that subset of patients has a condition called rotator cuff tear arthropathy or rotator cuff tear arthritis. And they develop not only pain, but really significant loss of the function of their shoulder.

So with traditional arthritis, people will have pain and lack of motion. With patients with a rotator cuff arthropathy or arthritis associated with a rotator cuff tear, not only have the pain and lack of motion, they actually have lack of function. They can't get their arm over their head. So it's quite debilitating and really becomes a source of frustration for our patients.

Alyne: But now some rotator injuries can be managed with physical therapy. And so when do you recommend surgery?

Dr. Chappell: Well, certainly folks who have small tears or partial tears, or the rotator cuff is predominantly just inflamed, those folks often can be managed just with physical therapy. And sometimes we trial an injection to help calm down the symptoms and help improve the outcomes from physical therapy. We have to be real careful with the injections though, because too many injections can result in weakening of the tendon and make it more likely to tear.

And then folks who've failed those things, they've had physical therapy injections or they have a complete tear where the tendon is pulled off the bone. Those folks often require surgery and the majority of those folks get surgery, what we call arthroscopically or with small keyhole incisions and the camera. And we do this through really small incisions and we actually repair the rotator cuff. We actually tie it back down to the bone. We tie it back down to the bone so that it heals back to the bone and they actually can return to pretty much full function with no pain after these surgeries.

However, in some cases, the tear is so bad that we cannot repair the rotator cuff, or they have arthritis already setting in associated with their tear. In those patients, we have to go on to do a special type of replacement.

Alyne: So let's begin first with the minimally invasive techniques that have just recently been developed. How recent is that?

Dr. Chappell: It's something that probably began about 15, 20 years ago, but over the last five to 10 years, the pendulum has swung to the point that we're almost a hundred percent of the time doing these surgeries through really small incisions. When we first started training, it was the exception to do these surgeries through small incisions. And I've been in practice now for 14 years. And when I first started practice, it was more common than not that we still had to make larger incisions.

Now I'd say over the last 10 years, I haven't made a large incision for a rotator cuff repair on any of my patients. We're doing all these surgeries now through small incisions, which helps with improving their outcomes and also minimizing the pain and the scarring, which also helps with improving their physical therapy and starting them right away. So these patients are much happier and have basically the same outcomes, if not better outcomes.

Alyne: And the patient can go home that same day.

Dr. Chappell: We're routinely doing these surgeries now as an outpatient. And in fact, I think we'll find over the next couple of years, many of the shoulder replacements, which previously had always been done in the hospital, are going to be done as an outpatient in surgical centers or ambulatory surgery centers. We are now starting to do total shoulder replacements in these centers and patients are going home the same day.

Alyne: So what is reverse total shoulder arthroplasty?

Dr. Chappell: So to understand a reverse total shoulder arthroplasty, you probably need to understand what was the traditional shoulder arthroplasty. And this is similar to a knee replacement or a hip replacement where we're basically resurfacing the joint, in this case the shoulder joint, without actually changing the mechanics of the shoulder. What we do with our traditional shoulder replacement is we detach the rotator cuff muscle in the front of the shoulder, allow us to dislocate the shoulder, and then we cut the ball in a way that we can put a metal stem inside the canal of the bone, and then put the metal cap on top and then put a piece of plastic to resurface the socket. Then we put the shoulder back into position and then repair the rotator cuff. And that's a traditional shoulder replacement. It's basically a resurfacing of both the ball and the socket side of the shoulder joint without changing any of the mechanics. You have to have a very good functional rotator cuff in order to have this surgery.

With the reverse shoulder arthroplasty or shoulder replacement, we actually flip the components around. We actually put a plate onto the socket, which is normally flat. And then we put the ball on that side and then we make the same cut we would normally make and take away the ball and make the ball side now flat, and then put a metal stamp on that side and then put a piece of plastic in its place. So the two components are reversed or flipped on opposite sides.

And the common question that comes up is why would you do this? The reason why we do this operation is it actually changes the mechanics of the shoulder. It utilizes the large muscle on the outside of the shoulder. That muscle is called the deltoid muscle and it actually bypasses the rotator cuff and allows that large muscle to actually do all the movement of the shoulder. So now you have bypassed the torn rotator cuff and used the large muscle around in the shoulder, which is perfectly functional in all these patients, and it converts that movement of that muscle to allow you to bring your arm up over your head with nearly the same range of motion you had previously. So it's a real game changer when it comes to these patients and their outcomes and, honestly, their functioning and their normal lives.

Alyne: So I know as a sports medicine expert, you also see younger patients with sports-related injuries and I've heard that you can really push advanced medicine now to take care of their problems, to ward off future problems like arthritis. Can you talk about that?

Dr. Chappell: Absolutely. You know, start to finish from teenagers all the way up to the elderly population, we can handle all shoulder needs. And that includes the earliest things which we often see, which are shoulder instability, where people are dislocating their shoulder, all the way up the rotator cuff injuries and then eventually shoulder replacements. The goal throughout all of this is to provide a functional shoulder that will last a lifetime and try to avoid shoulder replacements by avoiding arthritis.

Now, the fortunate thing is we have some wonderful operations for when we do reach the point where the shoulder has become so arthritic that we can then introduce these new operations, the reverse shoulder replacement, which provide great function. But as always, our goal is to do as minimally invasive a surgery as possible to restore function and minimize pain in these patients. So all the operations we do now for the most part are done arthroscopically until we reach the point of doing shoulder replacements.

Alyne: And if a person does need to stay in the hospital, it's a shorter stay.

Dr. Chappell: Absolutely. In fact, everything's moving away from the hospital, but even the patients now who do need surgeries in the hospitals, it's always an overnight stay. One of the best things that we've developed over the last year is we have new anesthesia techniques. We call it regional anesthesia where they're able to block the pain receptors in the arm for now up to two to three days. So patients previously could go home and have pain relief for maybe 12 hours, maybe 16 hours. These patients now are routinely having complete relief of their pain for two to three days. And that's allowed us now to do more complex operations, such as fracture care and shoulder replacements in the outpatient setting.

So while a few patients, when they have medical risks, they need to be watched for medical reasons, stay in the hospital, we're definitely moving towards the majority, if not all of our patients, being done as an outpatient in an ambulatory surgery center outside of the hospital.

Alyne: Really terrific news. So finally, do you have any tips for our older listeners on how they can lessen their chances of developing a rotator cuff injury?

Dr. Chappell: Absolutely. First and foremost, we have to make sure that you're doing things safely. So avoiding things where you're going to be on ladders or areas where you're going to be leaning over or lifting heavy objects, particularly around this time of year when we have Christmas decorations going up and people are lifting trees or hanging lights on ladders. So try to make sure you're in a safe environment when you're doing things around the house.

Certainly, the same with doing yard work. Get some help. Try to get some younger relatives or neighbors to help with heavy lifting so that you're not putting stress on the shoulder. Furthermore, try to maintain some type of program to keep the muscles around the shoulder strong. So I recommend all my patients when they get into their forties and fifties to start maybe some exercise programs to strengthen the rotator cuff. Maintaining flexibility is also very important, because these things can compound on each other and they can result in injury.

Alyne: Well, thank you very much, Dr. Chappell, for joining us today. It's really reassuring to know that one's options in dealing with this painful shoulder issue could be resolved.

Dr. Chappell: We're making strides every year. And our goal is to make sure that everyone can have a long, healthy, happy life with no shoulder pain.

Alyne: Dr. Jonathan Chappell is an orthopedic surgeon and sports medicine specialist at Wake Orthopaedics. To learn more about WakeMed's Orthopaedic services, please visit WakeMed.org/orthopaedics. I'm Alyne Ellis with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. Stay well.