In this episode of #AskMikeReinold, we talk about working with patients with full thickness rotator cuff tears, some of the treatments we would focus on for those trying non-operative physical therapy, and they can even avoid surgery. To see more episodes, subscribe and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 197: Treatment of full thickness rotator cuff tears
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Mike Reinold: In this episode of Ask Mike Reinold, we’re talking about dealing with rotator cuff tears at full thickness in a non-operational way.
Fernando: Brian from New Jersey: “What has been your experience working with individuals, particularly non-athletes, with medium to large rotator cuff tears, without surgery? I feel that some surgeons instill fear in some of the patients I work with, based on the MRI results, where they might prolong the surgery, or not need it, once they start PT depending on the objectives. “
Mike Reinold: Okay, so let’s call it a full thickness tear in a non-athlete. I really liked it because it’s more important in this world, there is much more. Full thickness tear. How often do we manage to fail? Let me ask a question. To what extent do we think this is the case? How common are full-thickness tears in the general orthopedic population?
Dave Tilley: I have seen a handful of my young careers.
Lenny Macrina: I would say somewhat common. Whether symptomatic or asymptomatic, yes.
Mike Reinold: Okay.
Lenny Macrina: Certainly.
Mike Reinold: So it’s probably not uncommon with age, right?
Lenny Macrina: Okay.
Mike Reinold: It’s probably an attrition problem, as we get there. This therefore raises a whole other question: are there many different types of full thickness tears? You can have a small full thickness, a large full thickness. I think that’s actually a big part of that question, but why don’t we start from there? So who has experience with non-operative full thicknesses that have worked well? Probably at university, right?
Lenny Macrina: Who has a tear and bursitis?
Mike Reinold: So what do you think, Len, why don’t you start? What is the key, for you, for someone who has full thickness and we are trying non-operative, what is the key for you, to make sure it succeeds?
Lenny Macrina: Yes, I mean, of course, they’re probably coming to you because they hurt. So I could say if they don’t suffer, leave him alone, but they probably have a functional problem. Which means they have pain, and probably some loss of movement, I’m going to assume. They are just not going to go to the doctor and have an MRI scan on their shoulder, they have something to do, limiting themselves. So if they are in pain, we have to try to calm their pain and if we can calm their pain, can we recover their function? If they come with a big shrug, if they have a big shrug, it’s not a good sign, but you can always make people stronger by strengthening the cuff or the deltoid is stronger to overcome, to control what is probably torn, which is an armband.
Lenny Macrina: So I would say calm their pain, make them as strong as possible and make a decision. Some doctors, as the person who sent the question said, put a little fear into it, whatever their wording. Maybe not all doctors do this, I think there are doctors who are very educated in the way they talk to their patients, but if this doctor knows the risks run by this person, their comorbidities … In research, this is something that shows, people can work with a torn rotator cuff and send them into rehabilitation. We need to control their pain, then work on a general strengthening program and give that person confidence that we can treat them better. I have seen cases that have improved and now take up this challenge and try to make them functional again. So I don’t know, very simplistic form but, Mike?
Mike Scaduto: Yes, I think the fear aspect from the doctors is really important. This may not be exactly what the doctor says, and he may not be deliberately trying to instill fear. But if someone tells you, a full-thickness tear in your rotator cuff, the patient may just stop after that, and then they automatically think they need surgery. So I think … Then they come to us, and they’re very worried about it, because they think the surgery is going to be a really difficult recovery. But we may be able to turn what the doctor said or give them hope that they can get over it and that we’ve seen people progress with it and I think it comes down to being able to make changes minors in their pain or minor changes in their function, as much as possible, from the start. It gives people hope and then sets expectations for them. It may be only very, very minor progress, but a move in the right direction will give them some kind of hope that it might get better than they think.
Lenny Macrina: I think Mike said that the amount of tissue involved is critical. An MRI will sort of pick it up, but I mean a little tear, you will definitely be able to avoid surgery. Right? And this atraumatic … We see more research showing that chronic tearing of the atraumatic cuff has a chance to heal, if not, has almost the same luck as surgery, because when they have surgery and we fixed the cuff, we do a second ultrasound or MRI look, probably between 5% and 90%, so the range is huge, as that is what research says, has a new tear one to two years after surgery. So almost everyone re-tears their cuff after having surgery to fix the cuff. So why are we going to have this more than $ 20,000 operation when they are probably going to tear apart again in the long run anyway?
Mike Reinold: So I’m going to throw a curved ball into this discussion, because if you look at people with the percentages who don’t do well with surgery, it’s the biggest, the most chronic, the most degenerative over the time. So let’s ask a question again now. You have a little tear now, right? It’s not painful –
Lenny Macrina: Is it getting worse? Yeah.
Mike Reinold: To me, it’s one of those injuries, the rotator cuff tears, that if we just say it’s asymptomatic, ignore the MRI and just let them keep doing it. It is certainly the type of injury that worsens over time. And then you go to the point where now you are in pain, now you are in pain. So I’m not saying … I’m a big proponent of non-operative rehabilitation. I’m pretty sure the literature shows that you are probably over 50% likely to do well with non-operatives if you get it early enough. So it’s interesting. So what are you guys doing? I mean, Dan, if you have something else, jump too, but what if there is no pain? What are we doing?
Mike Scaduto: I don’t know if they would go to the doctor, right?
Mike Reinold: Yes, that may be a good point.
Mike Reinold: It’s a good point.
Lenny Macrina: I don’t know and it’s going to be the only reason they hurt and then how long they … Because they hurt for a day, they don’t go to the doctor. They have been suffering for months, now they go to the doctor. It’s going to be the last ditch, “I have a frozen shoulder because …” something.
Mike Reinold: That’s right, yes.
Dave Tilley: Dad, I love you so much. It’s a perfect example.
Mike Reinold: But do you think your father is watching the podcast?
Dave Tilley: Absolutely not. Someone will pass it on to him.
Mike Reinold: I know my mom does. I know Lenny’s mom does. From time to time Lenny … Good old Janet will give us … What’s up, Janet?
Mike Reinold: They’re still watching but sorry, again. Okay, Mr. Tilley?
Dave Tilley: My father’s story is exactly what we’re talking about, where these people don’t sometimes go to the PT. My dad is a great guy, he played softball 10 years ago in a slowball league. And he was, “Oh, I’ll go back there and play.” So my father has no background for this and he goes out and goes very hard for three hours, in the outside field and then the pitch, which is not a quick pitch. He texted me and said, “Hey, I think my shoulder is a little disappointed. Can you help me? I just need a few exercises. “And I ask him to move. He says,” No, I’m fine, I have a little movement. “Had a huge sign of shrug. He couldn’t move his arm at all. He said,” Yeah , it’s going to work out. “So many people don’t have a problem until something breaks out for a day or two, or they can’t raise their arms, they say to themselves a problem. “But then three weeks passed and they said to themselves,” Okay, I’m better. “
Lenny Macrina: Has he been operated on?
Dave Tilley: No.
Mike Reinold: Okay. Sensational.
Dave Tilley: He didn’t go to the PT.
Dave Tilley: The reason I talk about it is that I told my dad that I was like, “Okay, that’s a warning sign. You have probably had symptoms or had problems before. And I wasn’t going to let him blindly do nothing. I was like, “You should do these exercises. At least warm up your arm a bit. Maybe try adding some exercises. But as you said, you can’t let these people say, “Nothing hurts or nothing is lost.” So it’s like, “Everything will be fine. Go on.” There is a reason why the cuff is probably irritated, be it a structural thoracic kyphosis or something like that. Or they just get super excited and go play three hours of softball.
Mike Reinold: This is probably what happens with most people, they have chronic postural adaptations, chronic degenerative changes in their tissue. And then they’re going to pretend they’re 10 years younger than they really are and they’re doing something they’ve not done in a while. And it sort of starts to cascade. So I think right there gives you the answer that we shouldn’t just ignore these and we shouldn’t just settle for the fact that they have asymptomatic MRI and that’s normal. This is not normal. If it was not torn at birth … Did it rhyme? Wait a bit, let’s find something. If it weren’t torn, when you were born …
Dan Pope: It’s not the norm.
Mike Reinold: You have to ..
Dave Tilley: Grab the bull by the horns.
Mike Reinold: You have to catch the bull by the horns. It’s t-shirt time.
Dave Tilley: That little bull with a cuff tear.
Mike Reinold: I mean, if it wasn’t that bad, then we wouldn’t have a rotator cuff. So it’s not supposed to be torn. So I think that’s the kind of point here. So if someone has that or someone has a little tear, there are certainly things we can do. Let’s shift gears a bit here and try to conclude with this. What is our rehabilitation strategy for this person? What is the key to their success? Who wants to get started?
Mike Scaduto: Yes, I think you should look at their function and obviously make a full assessment, but I think it comes down to the basics of restoring as much passive range of motion as possible, restoring active range of motion, isolated strengthening of the rotator cuff and scapular muscles, then resume a more functional type of training. If they are now taking training that gives them symptoms, you modify them in the short term, then gradually bring them back to what they want to be able to do.
Mike Reinold: And we’d probably see it more and more with the younger generation, probably now. It was fifty now, probably forties, maybe even late thirties, among aggressive fitness athletes, Dan. Because they have these rotator cuff tears. Again, they jump on Instagram and say, “I should work with this.” What do you say to these people?
Dave Tilley: It’s difficult. These are two different populations and I think that we are sometimes strolled for having tried to push back the athletes, because it is supposed to be this message of hope that everyone can heal, adapt and improve. It’s difficult because I think it’s similar, probably, and we don’t have research yet to support it, but for … Let’s say, a baseball player, where they’re going to have headline tears asymptomatic and pathology of work, earlier than the general population. It is therefore difficult to answer. Because I have definitely worked with people in their twenties who have a pretty bad cuff tear and the thought is, “Can I continue? Should I stop? “And then, here’s the problem, most rotator cuffs, over time, will tend to get worse. You have this whole idea of adaptation:” Do my fabrics adapt because my pain goes away? “
Dave Tilley: Well, I’ll tell you what, your pain goes down and you can get stronger, but your tissue can also get a little worse. So it’s quite difficult. I think looking at the symptoms is going to be important, but it doesn’t give you the full answer. I will tell people to go there every few years and maybe have the doctor check it again and see if the MRI is getting worse. The only reason for this is that there is a risk that you may have a retracted tear, potentially develop more arthritis and not be able to get the surgery that was the best. So reverse the total shoulder against replacing the shoulder. I see people in their 60s doing high-level CrossFit to have a good amount of arthritic changes in their shoulders. And at that time, it’s kind of like “What am I doing? What am I not doing? Is pain a guide? Is it not a guide ? “And I don’t think we have all the answers.
Mike Reinold: Yes, we are definitely getting there. And then I would just like to share one last thing with my experience with some of this. At the start of my career, we were doing a ton of seniors with massive rotator cuff tears that were beyond repair. And it’s the one thing people don’t get with people like Dr. Andrews … Well, he was Alabama. He still had surgery… He treated everyone in the community too, not just the professional athlete guy, so he got a ton of people just tears of chronic rotator cuff that were beyond repair and we got had a lot of success. Actually … I mean, it depends on how you define success with them, but we made them raise their arms again, we did them painlessly, we got them really good. We have always returned to this whole concept of suspension bridge that we are still talking about. Besides, who came up with that, is Rockwood? I don’t even remember it now.
Lenny Macrina: Rockwood and Mattson’s book?
Mike Reinold: I don’t even remember. So the concept of the suspension bridge is, you think, you get your shoulder and you look at it from above, if you think of a suspension bridge. As long as your anterior and posterior rotator cuff is really, really solid, it’s fine if you have a tear on the upper aspect or supraspinatus because these two can sort of steer the vessel. The anterior posterior cuff can allow them to raise their arms further. And we’ve had a lot of super functional people just by getting their anterior posterior cuff as solid as possible. So obviously, again, the most massive tear you have is a problem. It begins to extend into the infraspinatus.
Mike Reinold: But then man, you better focus on the minor miners. It is therefore better to know different exercises. Better to read the article we published in JOSBT which talks about these different EMGs, because you have to be able to touch this teres minor a little more, for example. So you can certainly do things. So I guess to answer yes, you can certainly succeed. I don’t think you want to be that guy riding your horse high right now, saying, “No one should have an operation!” “MRIs and being asymptomatic are normal.” I don’t think we want to go that far down the road. It’s a bit too far with that. But yes, we can succeed. Mike, what do you got?
Mike Scaduto: I just have to wrinkle in there. This is a question that I have in a way. Where do you think biologics … Genetic injectables like PRP, and even anti-inflammatories, corticosteroids and cortisone, fit into the rehabilitation process for someone who has a middle cuff tear at large?
Mike Reinold: Good question. So, actually … At the meetings I recently spoke to, there were a lot of good doctors who are great at biologics. The guys from Chicago to Rush are doing a great job. Brian Cole is sort of one of the leaders in this area and I have heard him speak on organic products a few times now. And then, obviously, anyone intervenes if you have experience. But I think right now the results are coming and I think the idea and concept of organic products on these people is there. I don’t know if it’s still there. But, another thing to consider here, if you have a full thickness retracted tear, I don’t think organic products will help with that. So, I don’t know how many organic products will help with a large full thickness retracted tear. Maybe if you have a partial thickness subsurface, I think, that’s what we’re going to be looking at. So, good question. I don’t know if it will necessarily help that. This could help with reconstruction or repair.
Lenny Macrina: That’s what I was going to say, is to increase it with repair. So if they can make some sort of PRP or STEM cell, which I don’t think I’ve seen yet, it works. Maybe we need…
Mike Reinold: I don’t know if we still know.
Lenny Macrina: We don’t know yet.
Mike Reinold: The concept is there and organic products are improving. I think that’s the other thing to do. As FDA regulations evolve, we will get there.
Lenny Macrina: And then even too, almost like an internal splint that we use for the ankles and elbows and we start to use non-human tissue. Collagen scaffolding for those types of tissue that failed in the 90s and early 2000s to try to use different materials. And I think we are revisiting an old concept and seeing promises. So I think there is something to watch out for. Superior capsular reconstructions, things of that nature. We have tears in areas that were never repairable before and the function has been lost. We can now use some of these new materials, and there are new promises, so we are definitely making gains.
Mike Reinold: Great. Great question. Thank you very much for asking this question. If you have a question, go to mikereinold.com, click on this podcast link and you can fill out the form to ask us questions. Ask us for anything you want, we’ll be happy to get it in a future episode. Thank you!