Rotator Cuff Disease of the Shoulder - James T. Mazzara, MD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest Dr. Jim Mazzara. Dr. Mazzara is an orthopaedic surgeon who did his medical school training at New York Medical College. From there he completed an orthopaedic residency at St. Luke Roosevelt Hospital, an affiliated hospital of Columbia University. Good morning, Dr. Mazzara.

Dr. Mazzara: Good morning.

Dr. Sechrest: Today what I would like to discuss is a relatively common problem of the shoulder, rotator cuff disease. Patients hear this term constantly and I think what I would like to do is try to clarify: 1) What is this problem with the rotator cuff? 2) A little bit about what is the rotator cuff? 3) What are our options for treating? So if you could start out by just clarifying this whole concept of what the rotator cuff is?

Dr. Mazzara: Well, the rotator cuff is actually a set of four muscles and tendons that help stabilize and move the shoulder. The muscular part of the rotator cuff actually starts in the back of the shoulder blade and, as it goes out to the shoulder, it converts and changes from muscle to tendon. Those four tendons then blend together as a cuff and attach to the upper part of the bone called the humerus. The rotator cuff functions in a number of different ways. It actually functions to stabilize the shoulder joint keeping the center of the head of the humerus in the center of the socket. In addition to that, while it’s working with the muscle called the deltoid muscle, it serves to elevate and rotate and move the shoulder. So the rotator cuff is actually a set of muscles and tendons and the cuff part is what we could consider the tendinous part of rotator cuff. That part is the part that gets the patients into the most trouble. The muscle part is actually attached to the tendons and helps move and stabilize the shoulder.

Dr. Sechrest: When we talk about the whole concept of rotator cuff disease it goes by lots of different names – impingement, there are rotator cuff tears, there are all sorts of different ways we refer to this. Can you describe for me a little bit so that patients can understand how these conditions happen and what happens in that continuum of problems that we call rotator cuff disease.

Dr. Mazzara: Well, the rotator cuff can get into trouble as we get a little bit older, as we become more active, or sometimes as we just stress the shoulder. We see rotator cuff trouble in young athletes. Those are usually athletes who are doing very strenuous kinds of activity – baseball pitchers, for example, and weight trainers, can typically stress and strain and create partial tears in the rotator cuff. As we get a little bit older however just the normal wear and tear changes that we all go through cause secondary changes in the rotator cuff. There is a certain area in the rotator cuff where there’s not a great deal of circulation that tends to be a zone of the rotator cuff, in the front of the shoulder just as it attaches to the bone, which is at risk, and that little area at risk has very poor circulation causing any stress and strain to cause little microscopic tears in the tendon; and as those microscopic tears progress and worsen over time sometimes patients will develop symptoms as it relates to that. So a partial tear can end up developing a full tear, and full tears, a full perforation through the tendon, can actually progress and will progress over time.

Dr. Sechrest: Now there are a couple of terms that I want to make sure that patients hear, because they’re going to hear them from their physicians and other folks, and one is the concept of tendonitis; the concept of tendinosis, which I think more and more surgeons have a tendency to use for these problems rather than tendonitis; and then the whole concept of bursitis. I think everybody with shoulder pain thinks they have bursitis.

Dr. Mazzara: True.

Dr. Sechrest: Clarify those three terms for me.

Dr. Mazzara: Well, there’s a technical difference, but as physicians and orthopaedic surgeons we tend to blend those things together. Somebody may come in and think they have a bursitis. Technically, the bursa is a separate structure. It’s a sac-like structure that sits between the rotator cuff and the bone and a little ligament on top of the rotator cuff and it actually serves to lubricate and facilitate motion between the bone and the rotator cuff. If that structure alone becomes inflamed, you’ll have a bursitis. The problem is, very often, we see patients in the office who don’t have an isolated bursitis. They have a little bit of inflammation of the tendon, technically we’d call that a tendinitis even though, in the office when I examine patients, I tend to use those words interchangeably. I prefer the word tendinitis because I think there is more tendon pathology than pure bursa pathology. Younger patients may get a bursitis. As we get a little bit older, in our 30s and 40s, we may get a little more involvement of the rotator cuff tendons and then you have a tendinitis. There’s an inflammatory reaction in the tendon that causes the pain, inflammation is what causes the pain in many cases. The term tendinosis however is a little bit different. You can have a tendinosis and really not have a lot of pain. Tendinosis is more of a wear and tear phenomenon in the tendon itself. It’s these little partial microscopic internal tears in the tendon that may or may not cause any problem for you. We may see it on an MRI. We can do an MRI on a patient and fined tendinosis or tendinopathy, for example, and that patient may or may not have any symptoms from that, but it’s evidence of wear and tear. It’s, for better for worse, a part of life. It’s what we all go through.

Dr. Sechrest: Now, one other term that I want to add to the mix, and in some ways we consider this a little different disease process, but it’s all part of the continuum. That’s this concept of impingement in the shoulder. Can you describe to me the concept of impingement and how that may create these things like bursitis, tendinosis, tendinitis.

Dr. Mazzara: Impingement is more of a clinical term, a clinical presentation, it’s more of a syndrome, and it’s associated with bursitis, tendinitis, or tendinosis. It’s actually when the rotator cuff may rub against the structures that sit on top of the rotator cuff. The structures that sit on top of the rotator cuff are the acromion, which is either a flat or a slightly curved shaped bone, which is attached to a ligament, called the coracoacromial ligament, that in turn creates an arch over the top of the rotator cuff. That arch is very important for function but at the same time as that little space or interval between the arch and the rotator cuff becomes crowded, you’ll get important. It’s more of a clinical presentation, so patients who may come in with shoulder pain can have terms thrown at them like tendinitis, bursitis, impingement; they all really mean the same thing which is there’s not enough space between the bone and the tendon. That tendon is then inflamed or painful and there may be friction between those two structures and that friction is in part what causes the pain. It can also crowd and compare the space available for the cuff underneath causing damage to the cuff.

Dr. Sechrest: Now, we talk a little bit about what all these things mean. Let’s move on and talk a little bit about what causes these. Is this something that is genetic in origin? Is it something that comes from an injury or is it something that we’re all going to get as age? Is it a condition of aging?

Dr. Mazzara: Well the answer is there’s probably a little bit of all of that involved but I think more of this, more of impingement and tendinopathy or tendinitis, is either activity induced – you’re doing something that’s aggravating the rotator cuff, and it’s much more common as we get a little bit older. In younger patients it’s probably not as much age-related because those are people in their teens, and 20s and 30s. It’s more activity related. So they’re doing something that’s stressing and straining the cuff. Those younger patients may have a tendinitis without actually having impingement though. They may not actually be having any bone spurs or any thickening of the ligament pushing on the tendon creating a problem for them. So it depends on the individual patient – younger patients who have instability, for example, may have extra motion or extra laxity of the joint. Those people could have a secondary tendinitis of the shoulder, and those younger patients, very common in teens, 20s, and 30s, may actually need to be treated for that instability by stabilizing the shoulder either through exercise or surgery as opposed to addressing the tendinitis, because the tendinitis ends up being secondary to that instability.

Dr. Sechrest: The other that, in my experience, has been a real problem for people. For example, if you’re a muffler guy, I think you’re at higher risk. Anybody that works day-to-day overhead tends to have a problem and that includes swimmer’s, the younger people that includes the throwing athlete, it includes anybody. If you can see yourself as the muffler guy working overhead constantly, I think those folks get that impingement a little earlier than the normal person.

Dr. Mazzara: Absolutely. I would agree with that. I see a lot of working patients who come in who are electricians, plumbers, and carpenters and do a lot of overhead work. It’s for some reason very common in people who paint and do a lot of painting overhead as well. Those are people who are very frequently self-employed and need to get better fast and get back to their work.

Dr. Sechrest: The other thing that tends to happen and people hear about all the time is this concept of bone spurs. There are bone spurs in the shoulder causing impingement. Can you explain a little bit of the role of that degenerative change both in the joint above the shoulder, the acromioclavicular joint, and just in what we call the coraco-acromial ligament, where you get that bone spur that some people perceive is part of the problem.

Dr. Mazzara: The acromion is the bone that sits on top of the rotator cuff and it’s attached to a ligament. Anatomically and genetically it comes in a variety of sizes and shapes. As we age however, we may develop bone spurs, or little calcium growths on the end of the normal bone, that can grow into the area of the ligament and that bone spur that grows into the area of the ligament can actually steal space available for the rotator cuff. So it grows into the region where the rotator cuff lives and functions and as a result crowds the rotator cuff causing pressure on it. It can also impair the circulation to the cuff as it attaches. So many of the rotator cuff tears that we see aren’t actually on the top surface of the rotator cuff tendon. They’re on the bottom surface or on the articular surface as we would say and we can see them from inside the shoulder joint. Well, the idea is that if the bone spurs on the side of the tendon but that the first part of tear appears on the other side of the tendon, is that bone spur really cutting into or damaging the rotator cuff? Indirectly it is because it can air the circulation, because abnormal forces on the tendon can cause this tear. In addition to that, we just stress and strain our muscles and tendons. We’re not designed to be built to last forever, and we just go through a normal wear and tear process. As I mentioned initially, there is an area of circulation where the cuff attaches to the bone. That watershed area has very poor circulation so as we get older the stresses and strains of normal daily life will cause microscopic tears of the inner fibers on what we call the articular surface of the tendon, on the bottom surface, and those partial tears eventually progress to bigger tears over a period of time.

Dr. Sechrest: Now how does a person, a patient, know when this is occurring? When should they seek care? What symptoms should they be looking for?

Dr. Mazzara: Well, we all experience those wear and tear changes more often than not without knowing it. It’s when people are impaired and they have an ache or a pain that they can’t explain and it doesn’t go in a week or two that they need to ask themselves, “Why am I having this pain? Is this something is a problem that will go away, and many patients will come into the office saying, “Well, I thought it was going to go away and it didn’t, so here I am”. Quite frequently when patients can’t do their work, their leisure activities, and especially when they can’t sleep at night, they tend to come into the office, and the biggest issue is that they have pain that they perceive in the arm. Now shoulder pain starts up here in the upper part of the rotator cuff and the area of the insertion or attachment of the rotator cuff, the patients very frequently don’t feel it up here, they feel it down here. They feel it in the middle of the arm and sometimes as far as the elbow and even in more advanced cases, sometimes down the arm a little bit. As an orthopaedist we need to help get the information from the patient and find out when it bothers them and differentiate the multiple causes for shoulder or arm pain. So people may come in and say, “I have a deep ache over here or when I use my arm, I do certain things or I sleep or I do overhead activity then I have this shoulder pain”. In the initial stages of impingement syndrome or tendinitis of the shoulder, the symptoms may fluctuate, it may wax and wane over a period of time. You may have a good week and you may be able to do all of your physical activity, but the following week you might have increased pain and discomfort in the shoulder and so you tend to use it less. Over a period of time, there’s that pattern that we see associated with the previous activity. That’s the first initial phase of what we would call impingement syndrome or tendinitis of the shoulder. Eventually you get to the point where the pain never actually goes away. There’s always a certain level of pain there. It gets better and worse, but never quite goes away.

Dr. Sechrest: It’s interesting. You mentioned the pain in the mid-arm and in my experience I’ve had patients come in and they’re just convinced that the problem is in their arm and you can’t convince them it’s in the shoulder.

Dr. Mazzara: Absolutely.

Dr. Sechrest: The other side is that I see a lot of patients who have pain that radiates into the supraspinatus muscle and up into the shoulder blade and they wonder if it’s not coming from their neck and they may start getting a little neck pain.

Dr. Mazzara: I think that’s very important. You can have shoulder pain that refers back. But when you have patients who come in who report pain on the top of the shoulder or in the upper part of the back, you have to pay a lot of attention to the cervical spine. You have to examine their neck and make sure they don’t have arthritis of the neck referring symptoms to the upper part of the shoulder. You also have to examine the other very important part of the shoulder, which is their acromioclavicular joint. Patients will frequently have a little bit of arthritis up here where the clavicle attaches to the acromion. There’s a very small joint there, it’s about the size of a couple of nickels stacked together and that little tiny joint, as it becomes arthritic and wears out, develops bone spurs as well. So those bone spurs are significant contributing factors to impingement as well. It’s not just that bone spur that grows into the ligament on the acromion, it’s the bone spur from the arthritis in the acromioclavicular joint that puts pressure on the rotator cuff underneath. Underneath that bone spurs is where the rotator cuff lives and functions. The less space there is for the cuff, the more trouble your cuff is going to have doing what you want it to do.

Dr. Sechrest: The other thing I’d like to bring out, and see if this is in your experience, one of my things that I ask patients is when they sleep. They get pain, especially if they sleep with that arm up like this, so they’ll wake up in the middle of the night and that shoulder will just be aching because they’re in that impingement position.

Dr. Mazzara: That’s absolutely true and as I mentioned, that’s when people come into the office. They could put up with it when they were at work or when they were out on their leisure activities, but when they can’t sleep, it makes for a very unhappy patient when they come in.

Dr. Sechrest: When that patient presents himself to your office, how do you go about trying to make this diagnosis. Is this a clinical diagnosis that you feel like all you need is a good history and physical? Do you do any radiological imaging? How do you proceed with a patient like that?

Dr. Mazzara: You always have to start with a good history and physical. You always have to ask patients do you have activities that bother you? When does it bother you? How long does it bother you? Was there a sudden event? Is there a sudden event that caused this to occur? In that sudden event was there a rip or a tear? Did something else happen or was it just kind of a slow gradual onset of symptoms? In addition, you want to know if they’ve had any treatment? You also want to ask them if they have any numbness or tingling in the upper extremity. You want to make sure that you’re not assigning shoulder pain to the rotator cuff when in fact it might be coming from something else, so thinking about all the other contributing factors to shoulder pain is an important part of the evaluation. Then we examine the patient. After we’ve taken a good history and we want to know what treatment they’ve had we want to examine the patient. We want to look at the position of the shoulder. We want to see if there’s atrophy or asymmetry compared to one side. Do they have an obvious bone spur? Do they have something that’s clear and you can see visibly, then you do a physical examination. In your physical examination you want to ask them to range their shoulder throughout a full range-of-motion. Many patients can do that and some patients can’t. Those who can’t may have another contributing cause to their shoulder pain. Other common causes to shoulder pain are things like frozen shoulder, adhesive capsulitis or arthritis of the shoulder. Do they have a lot of weakness in the shoulder? Do they have a normal neurologic exam of the shoulder? Can they move their hand and wrist? Do they have normal reflexes in the upper extremity? Once you’ve done a very thorough physical examination and you’re somehow convinced that this is rotator cuff disease or arthritis or frozen shoulder, you have to do a proper set of x-rays and a standard set of x-rays is not always appropriate. There are very particular views that orthopaedic surgeons like to get. We like to see a clear shot through the glenohumeral joint, through the shoulder joint. We like to position the shoulder in such a way where we can see if there’s a bone spur, we can see if there’s arthritis, and if there’s arthritis, how much? Doing those x-rays by the orthopaedist is actually very important because we typically position you in a certain way that, let’s say, your radiologist or medical doctor may not order these very specialized views. Once we have done that then we can come back to the patient, even before we do an MRI and say, “This is your history. This is what I think your diagnosis is, and these are your options.” We always lay out all of our options for the patient from the simplest thing to the most complicated and at the end of all that may make a recommendation. My own personal philosophy is that I’d like to do the simplest thing that works and discuss with the patient, get some idea from them how they feel about that.

Dr. Sechrest: Now when do you move on to getting an MRI scan? What triggers you to go from those x-rays to say, “I need some more information. I’m concerned about other things.” What other tests are you going to do at that point?

Dr. Mazzara: Well, it’s going to depend on the patient’s history. If a patient comes in a slow gradual onset of shoulder pain and I think they have an impingement syndrome or tendinitis and they have not had any treatment, we need to start some conservative treatment. We need to start with activity modification. We need to start with an anti-inflammatory. There are a number of anti-inflammatories that are available; some are prescription, some are over-the-counter. Then we also talk about corticosteroid injections, which can be very helpful and sometimes give patients a dramatic degree of improvement initially, but anti-inflammatories or a cortisone shot are not generally going to be the cure. They are a part of the solution and the other part of the solution very importantly is going to be physical therapy. In many cases patients can do therapy on their own, and many patients that can’t need the supervision of a therapist. So we might recommend therapy for a number of weeks. We might recommend therapy for 3 or 4 weeks and a re-evaluation to assess how they’ve done with therapy. How they do with either the shot or the anti-inflammatory and discuss with them whether or not they think more conservative treatment is going to be beneficial. If somebody comes back 4 weeks later and has absolutely no improvement in their shoulder pain, I have to wonder why aren’t they getting better? Is there something more serious in there and I might opt for an earlier MRI than if somebody’s coming along and getting better every few weeks or so with therapy and home exercise I might be more inclined to wait 2 or 3 months before doing an MRI.

Dr. Sechrest: So it’s not a knee-jerk reaction for you, as an orthopaedist, to get an MRI scan necessarily on that first visit for shoulder pain?

Dr. Mazzara: Not if the patient has a slow and gradual onset of symptoms. On the other hand, if somebody comes in and says, “On Thursday, my shoulder was fine. On Friday, I had an injury and now I have pain. I can’t lift my arm.” That’s an immediate indication to me that they have had some kind of an acute injury. I would be much more inclined to do an MRI on that patient if they have findings that I think suggest a tendon injury to the rotator cuff, possibly a tear, because under those circumstances I would like to let that patient know that if they have a tear they have some other options available. Again, that would depend on the individual patient and how old they are and what their functional capacity is.

Dr. Sechrest: I think we also ought to mention that you mentioned the whole concept of pain being referred from other places like the neck, and sometimes, again we, as orthopaedists, look at that patient and say, “you know I’m really suspicious that this has nothing to do with your shoulder”, and all of the sudden we’ve gone from a patient complaining of shoulder pain to saying, “I want to get some x-rays of your neck and an MRI scan of your neck”, and they’re saying, “What are you talking about?”.

Dr. Mazzara: Absolutely.

Dr. Sechrest: So I think patients need to know that sometimes we go off another area looking because we’re suspecting that the problem is not where it’s presenting.

Dr. Mazzara: Well, that’s going to be based on our history and exam.

Dr. Sechrest: Right.

Dr. Mazzara: Quite honestly it can be very difficult initially to differentiate some of those patients and I’ve seen quite a few patients who have a combination of both. They have a bit of neck arthritis and a little irritated nerve in the neck causing some upper extremity pain, and they also have some rotator cuff disease. We also see patients who come in who we think may have rotator cuff problem when in fact the weakness in the shoulder is actually nerve related. I’ve had multiple patients come in with pinched nerves in the neck or even injuries to the set of nerves that comes out of your spine going to your shoulder called the brachial plexus where they come in with profound weakness, and we do an evaluation of the rotator cuff and the neck and sometimes nerve conduction testing is an important part of evaluating shoulder weakness. That’s something that we don’t necessarily do initially, it’s going to be based on the patient’s history and their physical findings and what our clinical impression is. If clinically, I think it’s a nerve problem, we will direct evaluation to the cervical spine either with an MRI of the neck or EMG. But, if I’m convinced from history or exam that it’s the shoulder, we tend to focus on x-rays of the shoulder initially and then later on an MRI. Patients who may be unable to have an MRI of the shoulder, for whatever reason, some patients who have pacemakers and can’t have MRIs can have a CT scan arthrogram. That’s another very good way to evaluate for a rotator cuff problem. It doesn’t give us quite as much information as an MRI would, but for patients who are unable to have an MRI of the shoulder, a CT scan arthrogram is a very good way to do them.

Dr. Sechrest: You’ve mentioned treatment to some degree when that patient presents as long as they don’t have something that you think is a serious injury such as an acute rotator cuff tear that needs to be dealt with immediately. You mentioned that sort of conservative treatment then moving on to more invasive treatment such as an injection and you’ve mentioned physical therapy. Lay that out for me in terms of what your ideal path for a patient who has impingement rotator cuff disease, probably doesn’t have a rotator cuff tear, lay out a plan of what the patient should expect in terms of treatment and when you make choices such as: When do I do an injury? When do I stop these things and say they’re not working and move on to surgery?

Dr. Mazzara: I think initially, I’ll always have that discussion with the patient about either oral anti-inflammatories or cortisone shot, is there’s risk to taking oral anti-inflammatories just as there’s risk to anything else. When you kind of look at the risk and the benefit of oral medication versus a cortisone shot, if you think somebody doesn’t have a cuff tear a cortisone shot is a little bit safer and easier, the problem is patients very frequently don’t want to have needles, and I respect that and that’s okay; then the other option is oral anti-inflammatory. You worry about the side effects and heartburn and GI problems with oral anti-inflammatories and even interactions with other medications. But that’s part of the solution. The other part of the solution is going to be physical therapy. Physical therapy is going to be designed to stretch the tighter areas of the rotator cuff, to get the shoulder motion back to as close to normal as possible, and then strengthen the weakened portions of the rotator cuff with the therapist. Most patients can do that with a therapist. Some patients can do that at home. I do recommend a home exercise program when necessary but I think people better with therapy. I’ll generally see that patient 3 or 4 weeks later and evaluate how they’ve done. If somebody says, “Well, I’m 50% better” I think that you can reasonably and safely continue conservative treatment. They can eventually taper the anti-inflammatories if they’re on that and then you’ll see them a month later, and each time you evaluate those people what we’re trying to figure out is are we making them better. Has the treatment we’ve recommended improved their symptoms to the point where they notice an improvement compared to where they were initially. If the answer is yes, you can continue; if somebody wants to check in every month or two just to make sure that they’re doing okay, and they eventually get back to normal, they don’t need to have an MRI of the shoulder. Those people who at 6 or 8 or 12 weeks of conservative treatment aren’t really getting better, and I don’t think they have a tear but they do have impingement, I’d probably recommend they have an MRI. If they have normal motion of their shoulder and they don’t have a frozen shoulder and they don’t have impingement, I think we need to go ahead and get more information to find out why they’re not getting better. There has got to be some reason and in many of those cases we’ll see a very large bone spur related to the bone spur in the acromion or related to acromioclavicular osteoarthritis that’s pushing on it and squeezing and sometimes even indenting the rotator cuff on the MRI. In many of those cases we might recommend other options available to those patients such as arthroscopic surgery.

Dr. Sechrest: Now I want to go back to physical therapy for a moment because I think a lot of people don’t understand what we’re trying to achieve when we send a patient to physical therapy. You said two very important things: 1) to regain full range-of-motion of the shoulder; 2) the strengthen of the rotator cuff muscles. Tell us why that’s important?

Dr. Mazzara: If the shoulder is not fully flexible and you don’t have all of your motion, your rotator cuff is not going to move normally. The center of the head of the humerus is not going to remain in the center of the glenoid; the head is not going to be in the center of the socket. As a consequence, what will happen is you’ll get this eccentric motion of the shoulder. As a result of that, you will get increased friction between the tendon and the bone, or the tendon and the ligament, or that arch overhead that we referred to earlier.

So you have to get all of your motion back. In addition to that, if you’re rotator cuff is weak, you won’t get normal function, normal motion of your shoulder and you’ll get this abnormal mechanics of the shoulder joint and that will cause increased friction and increased pain. If you can recover all your motion and get your strength back, your shoulder works better. It’s back in balance, for example. People sometimes describe the rotator cuff as trying to keep the ball and socket joint of the shoulder in balance. When it’s too tight in one area or too weak in another, it’s out of balance, and like any machine your joint will not function properly and the parts will be under increased stress and friction, and as a consequence of that you’ll have the pain in the shoulder. So you have to focus on stretching and eventually strengthening. Stretching is always primary. You want to get your motion back before you start pulling on elastic bands or lifting your free weight or doing an isometric exercise, because if you strengthen an otherwise painful shoulder you’re going to end up aggravating it, and people who go to therapy and find out that therapy aggravates their shoulder pain, may not be addressing the true pathology there and so the therapist needs to identify that. That’s one of the dangers of sending people home with exercises that they don’t always have the supervision of a therapist a couple times a week to clarify for them that, “Gee, you can’t do this exercise if it hurts”, or “You shouldn’t do that exercise that way”; or, if a certain exercise becomes painful there’s got to be another way to do that. That’s the value of seeing a very good capable experienced physical therapist.

Dr. Sechrest: Yeah, I think that’s so critical. I think that a lot of people just sort of feel like, well, exercise is exercise, physical therapy is physical therapy, and there are definitely refinements in that mix and you’ve got to do it right. The balance of the rotator cuff and the motion is so critical. The other thing I think is, as you pointed out, it takes time. This does not happen. You do not go to one visit to a physical therapist, get a set of exercises and 3 days later you’re well. This occurs over a period of time.

Dr. Mazzara: Absolutely. But I do understand that people have time constraints, they have work responsibilities, family responsibilities. It can be very costly for people to go to physical therapy, but there’s some value to that, and the value is that maybe we can get you better without having to subject you to an operation. After surgery, if you ever end up needing surgery, you still have to go to therapy after surgery anyway. So our goal is to make you better without having to have to operate on your shoulder and many patients can do that quite well, and I think they do it better, faster, and more effectively if they go to therapy.

Dr. Sechrest: Now, you mentioned corticosteroid injection or cortisone injections. I think we ought to define some parameters for patients because a lot of patients, as you say, they don’t want to have a needle stuck in their shoulder, they think that’s going to hurt, they think there’s all sorts of risks to it. The other thing is cortisone has a bad name. People sort of think, “Oh, I don’t want to do cortisone and my doctor might have told me I could only have 3 of these injections in my life.” Define your philosophy in terms of the utilization of a corticosteroid injection in the shoulder. When do you make that choice to do the first one? How many do you do over what time period? What are the risks and the benefits of having those injections?

Dr. Mazzara: Well, I think the benefit of having corticosteroids is that you don’t have to take a systemic anti-inflammatory. There are no other systemic interactions. The cortisone goes into the shoulder, it stays, it works locally. The nice thing is it’s done during a simple office visit. It’s an injection. I never tell patients they don’t hurt. Any injection you have may have some pain associated with it. It’s generally not as severe as patients think it would be. You don’t want to repeatedly use cortisone injections. I try not to do any more than 3 a year and quite honestly it’s not 3 a year, every year. If you need an injection now, I try to defer the next one for at least 3-4 months into the same area. But if you came back in a year or two, you can certainly have another one with no adverse side effects. Any medication used correctly can be very beneficial. People can always have side effects, but if you look at the side effect profile of a cortisone single injection compared to the potential side effects of oral anti-inflammatories, I think it’s safer to have a cortisone shot than it would be to take an oral anti-inflammatory. But, again, cortisone does have a bad name. It’s unfortunate because it is very effective. In terms of how many injections over a lifetime, well, we generally think of 3 injections into a single area over a period of a year. Quite honestly, I don’t do 3 injections a year in the same area every year. I think that becomes a misuse of cortisone. I think if somebody’s not getting better with a couple of shots of cortisone, then they need to have treatment. There might be rare exceptions to that and the rare exception might be the senior patient who, for medical reasons or age-related reasons, cannot have surgery, we might break the rule for a cortisone shot if they come back every few months or so and need another cortisone shot. It’s a matter of pain relief and function and comfort to that patient. I might opt to give them a little bit more than that. But for patients who can have other treatment options available, I tend not to recommend too many cortisone shots, just because I think there are too many options that are excellent that are better for patients.

Dr. Sechrest: Well, let’s talk about some of those options. I think that you mentioned the surgical options. In a patient with rotator cuff disease, let’s discuss some of the generic options available in terms of surgery. You mentioned arthroscopic surgery, but let’s look at the whole gamut of potential surgical options for those patients. Where do you start and what are they?

Dr. Mazzara: Well, I think if you can look at a patient’s history and look back and say you’ve had every treatment option offered to you. You’ve had the shot, you’ve had the anti-inflammatory, you’ve modified your activity, you’ve gone to weeks and weeks of physical therapy, and you’re at a point where you’re really not that much better and you have all of your motion in your shoulder. We’re not treating arthritis or frozen shoulder, and you’re at that fork in the road, and you can’t go back an undo the damage to the rotator cuff. You really don’t see the benefit or value of repeating the options you’ve had. You basically have two choices. Patients always have choices, not always good choices, but two choices nonetheless. One option is you can live with it. If you don’t have a rotator cuff tear it’s a matter of dealing with the pain. Some patients may opt to do that, but the other option becomes arthroscopic surgery, and arthroscopic surgery is an excellent way to rotator cuff impingement syndrome or tendinitis because a bone spur is crowding the space available for the rotator cuff. The way we do that is it’s an outpatient procedure. It takes an hour or less to do. We do it under what calls an interscaling block supplemented by general anesthesia. Interscaling block is a nerve block given to the neck anesthetizing the shoulder. Then we put several small incisions around the shoulder through which we put small instruments – one’s a camera, the other is a little motorized burr – and these are about the diameter of a pencil. We put these through these tiny incisions, into the rotator cuff area, into the joint that we looked at the rotator cuff. We inspect the rotator cuff and the rest of the shoulder and then we redirect the camera and the instruments in the area where the bone spur is on the top side of the rotator cuff. Once we have done that we’re able to identify the bone spur and any arthritis at the acromioclavicular joint, and take that out. We use a little motorized burr and what we do is we flatten out and smooth out the bone spurs and resect the acromioclavicular joint to make space for the rotator cuff. If there’s any exuberant bursitis in that area we’ll trim that back. If there are any partial tears in the rotator cuff, small partial tears, we’ll trim those and don’t necessarily have to repair those, and what we can do is make space available for the rotator cuff now. Under those circumstances, postoperatively, since we’ve not repaired the rotator cuff, is put people in a sling. The day after surgery they take off the sling. They take the dressing off. They can get in the shower. They can get the incisions wet in the shower. Soap and water and a couple of band-aids, and they can start using the arm as soon as the nerve block wears off and that can be within 24-48 hours. We generally like to see those people about a week or so after surgery. Many of those patients have at least half, sometimes more than half, of their motion. Most of those people will have almost all of their motion by about 2-4 weeks and there’s always some variability. People are different and can tolerate different degrees of pain, so how much motion you get back over what period of time will vary from one individual to another. What I tell patients is that an average patient, at about 3 months, will have about 75-80% of their function back and they’ll be doing almost everything they need to do at about that point. But still at 3 months is not going to be fully recovered. There are always going to be a few different things that they can’t do. It’s either I can’t do something overhead without having pain the next day, or can’t pull weeds, or I can’t throw a ball, or I still can’t sleep with my arm above my head. That full recovery takes about 6 months from a purely arthroscopic bone spur removal or what we call an acromioplasty. So full recovery is a little bit longer than 3 months, but people will come back at about the 3 month mark and say, “this is great, I feel much better. I’m almost where I need to be, but I did this and it hurt, or I still have a little bit of ache and pain, but they’re doing much better at that point. I get those benchmarks from having done hundreds and hundreds of shoulder arthroscopies and bone spur removals like this, and you create this composite average patient in your mind. So there might be patients who come back at a month or two who are doing exceptionally well who have no pain, who don’t need a lot of therapy, who go back and do all of their activities, and are playing golf the next month. There are also those patients who, even at 3 months, may take a little bit longer to get better. Some of those patients may risk getting a little stiffness in the shoulder and so when I say 3-6 months for almost complete or then full recovery, that’s really an average.

Dr. Sechrest: Well, what about that patient who does have a rotator cuff tear? How is that patient treated differently, and contrast that with the patient who doesn’t have a full thickness tear of his rotator cuff, and you can treat with the arthroscopic procedure? Is this still an arthroscopic procedure that you can repair the rotator cuff or does this require an open incision?

Dr. Mazzara: Well, it’s going to depend on the individual surgeon in many cases. If a patient has a partial rotator cuff tear, which really means that the tear is through only about a certain percent of the rotator cuff doesn’t exceed more than half of the rotator cuff thickness as it attaches to the bone. The rotator cuff attaches to the bone – it’s about 1 cm or 1.2 cm of attachment of tendon to the bone. If there’s a very small tear through maybe a millimeter or two of that rotator cuff, you can really trim that back. The balance of the rotator cuff actually functions pretty well if you remove the bone spurs and decompress the shoulder as well. Over a period of time that tear may progress but people don’t often need any more rotator cuff surgery after that. We all go through these wear and tear changes, so eventually they may have trouble with it but over the next several years, generally that’s not the case. If however, somebody has a partial tear that exceeds half of the tendon thickness, or even a complete rotator cuff tear, we like to repair that and most arthroscopically. It’s still surgery, so even though we may not be making large incisions on the shoulder, we do make smaller incisions. We’re still repairing the tendon back to the bone and while we’ve advanced technologically very quickly over the last several years with arthroscopic cuff repair, Mother Nature doesn’t recognize those technology changes. It still takes 6 weeks for the tendon to heal to the bone. It doesn’t matter whether you do an open repair, a mini-open repair, or an arthroscopic repair, the tendon takes 6 weeks to heal, regardless of how it’s fixed. The advantage of the arthroscopic however is that it’s a little bit less invasive and we can technologically get an excellent repair, and sometimes even better visualization and sometimes a better technique at repairing these if it’s a small or a medium tear. Now larger tears we can still fix arthroscopically and there are some orthopaedic surgeons who may really opt for a mini-open repair under those circumstances, and I think in my own hands it’s going to depend on the pathology. When you’re doing the arthroscopic surgery you have to look at the tendon and you have to look at the quality of the tissue and the quality of the bone and the kind of patient you’re dealing with. If it’s a large tear, the question the surgeons always have to ask themselves is “At the end of this operation am I going to have the best repair that I can possibly have if I do it arthroscopically?” If the answer is the bone is very poor, the tendon is poor, the tear is too large, there is absolutely no reason why you should make an incision, because that patient is not going to be bothered by the size of the skin incision, they’re going to be affected by the rotator cuff that may or may not be intact at a later point. There are a lot of risks to re-tearing rotator cuffs which maybe we can discuss in a bit, but over a period of time, we recognize that technology is great but Mother Nature doesn’t change or recognize technology so we can do better things arthroscopically through smaller and smaller incisions, but it still takes 6 weeks for that tendon to heal, and it’s still going to take a long time for that shoulder to rehabilitate.

Dr. Sechrest: Well, I think that is a key point. I think you mentioned that at 3 months the arthroscopic acromioplasty with an intact rotator cuff, that person’s pretty much back to normal with a few problems here and there and at 6 months they’ve pretty much forgotten they ever had this problem.

Dr. Mazzara: Absolutely.

Dr. Sechrest: Whereas with a rotator cuff tear, that’s more like a year before those folks fully . . .

Dr. Mazzara: It does take a long time. It may not be until 6 or 8 weeks after surgery that we allow active motion. So, as we talk about healing of the rotator cuff, there is going to be a 6 week period of time where there is not going to be any active motion of the shoulder. In active motion of the shoulder, the patient directs the arm to move and they’re actively lifting or moving the arm. Passive motion, on the other hand, is when a therapist moves the arm or they do what we call “pendulum exercises”, and that you have to restrict activity for about 6 weeks under those circumstances, sometimes a little bit longer. If we’re doing some rehabilitation for strengthening the rehabilitation may not start until 8 or 10 weeks, and it’s going to depend on the patient and the tear and the quality of the repair, which is indirectly a function of the tendon and the bone. So it’s going to take a longer time for those people to get their motion back. If we look at an average range-of-motion recovery following a rotator cuff repair, it’s really going to be very variable. It’s going to be all over the place simply because people have a different capacity to deal with pain and every rotator cuff tear is a little bit different. It’s been there for a different period of time and they’re in different states of preoperative function. So the better function you have preoperatively, the more motion you have, the smaller the tear, the better you’re going to recover. If, however, you are a patient who has a large tear, multiple tendons are involved. Poor quality tendon tissue, poor quality bone, somebody who’s over 65, it’s going to take a longer time to recover. If you have impaired function and you can’t actively lift the arm prior to surgery, not only will you take a longer time to recover but, in addition to those other risk factors, you have a higher risk of re-tearing.

Dr. Sechrest: There’s one other patient population that I think we ought to discuss to be comprehensive, and that is that patient population that a lot of people would consider they have a tendon tear that is too big to repair. You simply don’t have enough tendon material to replace it, put it back where it should be, and attach it to bone. How do you deal with patients in that category?

Dr. Mazzara: They’re a very tough category of patients and many of those patients are older patients, some however are younger patients and I think you can treat those two people very differently. In the group of older patients who may have an irreparable rotator cuff tear have several options, but they’re not really great options. Some of those people may benefit from therapy and anti-inflammatories. If we’re choosing for surgery and if they have pretty good function they’re offered a couple of choices. One is a simple debridement of the joint. If they have an unfixable rotator cuff you’re really not going in and removing any bone spurs, you’re not releasing any ligaments and the reason you don’t do that is because they serve a purpose. Those bone spurs are there to stabilize the shoulder. If you have an older patient who has an unfixable rotator cuff and you take out some of those bone spurs, they may not be able to lift the arm after the surgery. So you can go in and trim and debride arthroscopically some of the tendon or even release the bicep tendon by means of what’s called a bicep tenotomy, where you just go and you cut the biceps if it’s still intact, and removing the biceps tendon and cleaning up some of the debris can be very helpful. If, on the other hand, those people have a profoundly weak shoulder and they have what’s called a pseudoparalytic shoulder and cannot actively lift the arm and they have a lot of pain with that, another very good option is what’s called a reverse shoulder replacement. It’s not always the best idea for a younger patient who has that condition, but for older patients it can be a very good way to both relieve pain and restore function because a reverse shoulder replacement is technically a total joint replacement, but at the same time it helps us stabilize the joint and it gets patients to lift and move the arm by using one of the muscles that still is there and intact. The rotator cuff may not be operating and functional, but if their deltoid muscle – that outer muscle on the shoulder – if that’s functional and working, we can get many of those patients to lift and move the arm again. For a younger patient however, that’s not a reasonable option to do a joint replacement like that on somebody who may be in their 30s or 40s. Those are patients who may be good candidates for a tendon transfer and that’s a very different set of circumstances, a very special group of patients, and fortunately those patients are few and far between.

Dr. Sechrest: Well, I think we’ve pretty much covered the waterfront in terms of the continuum of rotator cuff disease. We’ve covered the impingement process, and the tendinosis process that doesn’t involve a tendon tear necessarily and the treatment of that and what to expect from that. We’ve talked a little bit about the full rotator cuff and how that’s different, and the key finding there, I think you said, is that really it’s about getting that tendon attached to bone and letting it heal; and how that occurs determines what the success rate and, in some ways, how long this is going to take to recover.

Dr. Mazzara: Right.

Dr. Sechrest: Do you have any other key points that you think patients need to know about rotator cuff disease of the shoulder and how they should go about making decisions if they’re faced with decisions.

Dr. Mazzara: Well, I think you have to have a lot of confidence in your orthopaedic surgeon to guide you directly, and to tell you that this is your condition, this is what I think we can do, and so you have to have a discussion and you have to become educated about what you’re options are. I think in many circumstances we recognize that people expect perfection and don’t recognize that sometimes their conditions are so severe that we might be able to improve their shoulder function and not really get them to perfection. I would love to be able to make every patient feel 20 years old again. The reality is we can’t do that. So, in many cases, we have to go in with a set of realistic expectations. For somebody who may have a small to medium sized tear and sometimes even an acute large tear, we might be able to get those patients 100% of function even if we can’t get them all of their motion back, they might be able to do everything they’ve done before without a lot of impairment, without a lot of pain. It might be far better off than if they left the shoulder untreated. On the other hand, patients who have very advanced rotator cuff tears, really have to go into their surgery with some realistic expectations of either having a debridement of the joint where we’re just going to go for pain relief and their function is not going to get any better, but we’re going to make them feel better by diminishing the pain, or they’re going to have to consider the possibility of that reverse shoulder replacement that I discuss with them.

Dr. Sechrest: Are there any downsides or complications of any of these treatments that we haven’t discussed yet? For example, what are the risks of just allowing a rotator cuff tear to just go untreated? So, if I’m a 50-year-old gentleman who has a rotator cuff tear and I’m just going to tough it out – what happens to that patient?

Dr. Mazzara: Well, there are very few guarantees we can make our patients in terms of surgical outcomes. We can promise that we’ll take good care of you and we’ll do our best, but when it comes to eventual outcome of surgery we can say 9 out of 10 times you may get this result. On the other hand, we can make promises related to untreated rotator cuff disease. If somebody has a partial tear or a small tear, we can guarantee that will not heal spontaneously. We can also guarantee that a small tear will get bigger and will get worse over time. What we can’t predict however is how much bigger and how much worse and over how much time. If you’re 50 years old and we assume you have a normal life expectancy, you’re going to be around for at least 20-30 more years, and you have a rotator cuff tear now, I can guarantee you it’s going to be there next year and it will be worse over the next several years. You’ll eventually get to that point in time where you’re going to develop what is called a cuff tear arthropathy. Now that may take quite a long time, but the small tear progresses, enlarges, and eventually retracts to the point where it’s unfixable so 10-15 years from now you’re still healthy and now 60-65 years old, and you can’t lift and move your arm. You’ve kind of lost that opportunity to fix it when you could and you’re at that point in time where your options are really not that great, and quite honestly at 60-65, if you have a cuff tear arthropathy, you’re not a candidate for a tendon transfer if you have arthritis of the shoulder. It’s either leave it and live with it or have that reverse shoulder replacement; and if you could have had that cuff tear fixed years before that, I think that would have been your better option. So, cuff tears don’t heal spontaneously. They don’t heal by themselves. Once they’re there, because the tendon is attached to the muscle, the tendon retracts once it’s torn, it pulls away from its bony attachment; that creates a gap between the bone and the tendon and doesn’t heal without an operation. We can fix it surgically now, but there is a time frame in which it’s done and we can get you the best result.

Dr. Sechrest: So it sounds like your advice to those patients would be that you’re probably better off taking care of that rotator cuff tear early on, fixing it.

Dr. Mazzara: Absolutely.

Dr. Sechrest: And in some ways that’s preventable for progressing to these other less treatable conditions.

Dr. Mazzara: Yeah. I think it’s easier to fix, better to fix, and better for your shoulder function going forward, to fix it earlier than later. We’re always faced with that working guy who can’t take time off from work. It may not be an emergency to do it in the next month or two but, at the same time, it would be ill-advised to tell that patient that they could wait a year or two or more, to fix that rotator cuff because, quite honestly, it may not be as easily fixable in the future as it is at that point in time.

Dr. Sechrest: Well, I think this has been a comprehensive discussion of state-of-the-thinking in terms of rotator cuff disease today so I want to thank you for sharing this with us.

Dr. Mazzara: Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you’re an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you’ll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.