March 18, 2025 • 20 mins
In today's episode I discuss...
-Who is at highest risk of RCT’s
-Clinical Exam vs MRI
-Pain vs function
-Advice we might give patients trying to decide if surgery is appropriate and so much more!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello everyone and welcome to episode 374 of the
OrthoEvalPal podcast.
I am your host, Paul Marquis,and I'm a physical therapist.
Today we're going to be talkingabout the painless rotator cuff
tear and how to manage it.
We're going to be talking aboutwho's at highest risk of
rotator cuff tears.
We'll talk about the clinicalexam versus MRI, pain versus
function advice we might giveour patients, you know, when
(00:23):
trying to decide if surgery isappropriate, and so much more.
But before we get started today, I just want to mention our
sponsors.
We have range master.
Range master is known for theirshoulder rehab equipment.
They offer products fromshoulder wands to finger ladders
, overhead pulleys to shoulderrehab kits.
Range master is your one-stopshop to help with the treatment
of frozen shoulders, post-oprotator cuff repairs, total
(00:46):
shoulder and reverse totalshoulder replacements, and so
much more.
If you'd like to get a freesample of Rangemaster's Blue
Ranger pulley system, just emailjim at myrangemastercom and add
OrthoEvalPal in the subjectline.
Now we also have MedCorpprofessionals.
Now I know the folks at MedCorpPersonally.
(01:08):
They are locally owned and afamily-operated medical supply
company.
They carry everything fromradial pressure wave units to
traction devices, resistancebands to compression garments.
Most impressively, though, istheir customer service.
It's second to none.
I know these folks personally.
They are great to work with anddo an awesome job at getting
the right products to you and toyour patients at a very
efficient time.
They are second to none.
(01:29):
If you're looking for medicalproducts for your clinic or
products for your patients, goto wwwmedcorprocom and if you
use coupon code OEP10, you canget $10 off a Sondra cervical
traction unit and if you usecoupon code FIRSTTIME10, you can
get $10 off your first order atMedcor on other products.
Welcome back everyone.
(01:51):
Oh boy, is this going to be alittle snowball episode?
I'll tell you, and you know,it's one of those episodes where
I have this idea I want to talkabout this.
It's like simple.
I'm like this is gonna be likea 10 minute episode and it just
rolls and rolls and rolls and Ijust want to keep going with
this and I just want to get intomy life course.
I'm going to be giving in acouple of months and just go on
(02:13):
with this stuff.
Um, so where do we even start?
Okay, I want to talk aboutrotator cuffs today.
And we are.
We're going to a place wherenothing is black and white today
, Okay, and you may get donewith this episode and say I
can't believe I listened to this, Like I don't know if I got the
answers I was looking for whenI got into this episode.
(02:36):
There's going to be a lot ofgray area here, but one thing
you need to remember is thatevery single patient who comes
in with a rotator cuff problemor a shoulder problem is
different than the previous onethat you saw.
I tell patients this all thetime.
I could have a hundred rotatorcuff tear patients standing side
by side.
They will all presentdifferently as far as active
(02:56):
range of motion, passive rangeof motion, pain levels and
function.
They will look different and Iwill treat every single one of
them differently, Okay.
So if you think you're going tocome to a course and you're
going to get the one answer foryour rotator cuff tear patients,
you're at the wrong course.
Okay, we need to teach you howto individualize, how to manage
(03:19):
these people.
Okay, Cause they're all sodifferent.
I mean, think about it.
There are two over 250,000rotator cuff repairs done every
year in the United States.
40% of people over 60 years oldhave a rotator cuff tear.
Okay, Now, that could besymptomatic or asymptomatic.
Now, if you take 100 peoplethat don't have shoulder
(03:42):
problems and you MRI them or doa diagnostic ultrasound, you'll
find that 40% of those peoplewill have partial rotator cuff
tears and up to 46% will havefull thickness rotator cuff
tears, but they're asymptomatic.
They wouldn't even know thatthey had it.
Okay, so I can't even, you know,try to figure out how many
(04:04):
patients with rotator cuffs I'veseen over my 33 years of being
a PT.
I know that, like if I were tothrow all shoulders together, I
just couldn't even put a numberon it.
It's astronomical, From frozenshoulders to impingement, to
proximal bicep issues, to labraltears, you name it.
But we do see a tremendousnumber of rotator cuff tear
patients.
I think we had like seven oreight in the clinic the other
(04:25):
day, you know, pretty much allin one morning amongst the
therapist and myself who were inthat clinic.
So I've seen a lot of them.
One thing I'm going to try toinstill today is, you know,
treat everybody individually ifpossible.
So what I want to do today, too, is I want to discuss my
thought process on how I managethese patients who have, more
(04:45):
specifically, a non-painfulrotator cuff tear.
Okay, so I'm going to starthere with a patient presentation
and it's a 54-year-old male andit's not me, although I do have
a small rotator cuff problemwhich I'm working on right now,
but it's coming along nicely.
So, but we do have a 54 yearold male who I bump into at the
(05:10):
redemption center, knew this guyfrom a long time ago.
I'm like, hey, how you doing?
And he's like great.
But I just said I just recentlyhurt my shoulder and I'm like,
oh really, no kidding.
I said try to lift your arm.
And he couldn't like lift hisarm off his side.
It was crazy.
So I suggested he come see me.
I took a look at him.
I was 100% sure he had arotator cuff tear and so I set
(05:30):
him up with an orthopedicsurgeon and he met with this
surgeon and the surgeon says youknow, have you ever had a
rotator cuff tear in the past?
And he said yes.
He says well, he says I suspectthat I did.
He says well, he says I suspectthat I did.
(05:51):
He said I had three episodesthat hurt my shoulder, but each
time I did it I lost more andmore function.
And so, you know he, thesurgeon, said well, you know,
you have a MRI diagnosed rotatorcuff tear.
You clinically look like youhave a rotator cuff tear, we can
do surgery anytime you want.
And so he came to me and said Ireally need your opinion on
this if I should have this ornot.
And so his worry is that he thelength of time to recover and
the pain associated with thesurgery.
(06:12):
And he reports to me that, eventhough he can't use his arm
very well, he doesn't have anypain no nighttime pain, no
daytime pain.
I ask him about pain withfunction, he says he doesn't do
much.
He uses a computer at his work,he's a minister on the side and
he just doesn't do a lot ofphysical activity around the
(06:32):
house.
He says I I can do everything Ineed to do, I can take care of
myself and I just don't havethis pain and I don't really
want to undergo.
He said I've seen people whohad rotator cuff repairs done
before and they're in severepain for a long time.
They're in a sling, you know,and they're really out of
commission and whatnot.
So let me just paint you thephysical picture of this
(06:54):
gentleman.
He has active flexion of aboutzero to a hundred degrees,
abduction zero to 80 degrees,external rotation to about 45
degrees.
This is all actively Internalrotation to about 60 degrees.
Now his passive range of motionis significantly better, but he
does have a little bit ofcapsular tightness at the end
(07:15):
ranges, and he should right,Because he hasn't been lifting
his arm overhead, he hasn't beenreaching way behind him to put
his jacket on, because he justcan't move that arm that much
and so he just doesn't go there.
So we expect his capsule to betight.
All right Now.
Manual muscle testing is prettyawful.
Flexion abduction three minusover five.
(07:36):
Obviously you can't even get itto full range of motion.
External rotation two plus tothree minus over five max.
Now when I resist his flexionabduction, external rotation, he
has a significant shoulder hike.
Internal rotation is about 4plus over 5.
He has very poor humeral headdepression.
(07:56):
His cuff is not depressing hishumeral head whatsoever.
So the patient asks me what doI do?
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(08:25):
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Speaker 1 (08:41):
Well, folks?
Number one is it my place totell him what he should do or he
shouldn't do?
Now I know he comes to me.
He says listen, I know you havea lot of experience.
I totally trust you.
You have great rapport withyour patients and great outcomes
.
And I'm not patting myself onthe back.
I'm telling you what thepatient is telling me and I've
seen a lot of things and I'velearned a lot of things when I
(09:03):
was a young therapist and Ireally was able to sort out a
lot of these things a little biteasier.
But oftentimes there is nodefinitive answer.
So is it my place to tell thispatient yeah, you should go
ahead and have your rotator cuffrepaired, because we know
there's a high risk that you'regoing to develop osteoarthritis
(09:23):
of your shoulder early and thatcould be a problem.
Maybe he'll develop someatrophy, some weakness, maybe
later on develop some pain.
Number two do we tryconservative treatment and see
what happens, or do we just waitand see how this transpires, if
he goes on with his everydaylife and maybe we check him out
(09:46):
in a month or two months and andsee how it's?
It's going okay.
So he's 54 years old, he has noarthritis.
He doesn't have pain andfunctionally he can get along.
So what do we do?
So my question to you is do allrotator cuff tears need to be
repaired?
And the answer is no.
(10:08):
I have a patient now who came inwith he was in terrible shape
with a torn rotator cuff and alabrum.
He opted to try PT reluctantly.
His doctor said, well, let'stry some physical therapy.
And obviously when I saw him hehad a torn cuff, he had issues
with his labrum, he hadsignificant loss of motion.
He first, when he first tore it, he had a big fall and he said
(10:31):
his pain was severe.
For a day or two he could notlift his arm and then for about
a week it got better and betterand better and then he could
start to lift his arm a littlebit better and then it just got
progressively worse after that.
So he came to see me.
I want to say it was four orfive months after the onset of
this injury and he was justmiserable.
(10:53):
And I said I educated him aboutyou know what a rotator cuff
tear is, what a labral tear is,and that I've had many patients,
even in the last couple ofyears, who have complete rotator
cuff tears who get better andthey're comfortable and they're
fine.
But if they don't get better,then we have the option of
surgery.
So he opted for physicaltherapy reluctantly, and within
(11:15):
two visits he was significantlyshowing improvement in regards
to his function.
And what had happened was hehad developed a frozen shoulder
after the injury.
So not only did he tear hisrotator cuff in his labrum, but
he developed this frozenshoulder.
That that's why he got betterat first, and then he
progressively got worse and thearm got stiffer.
So he managed his adhesivecapsulitis and guess what?
(11:37):
He started to develop betterand better range of motion.
He's 95% better now.
I saw him just a couple ofweeks ago and I'm going to do a
check on him in another monthjust to see how he's doing.
But he told me I cancomfortably live the rest of my
life like this.
He says I don't want to havesurgery, I'm very functional,
I'm a pharmacist, I also do alot of work outdoors on the side
(11:58):
and I can do everything I wantto do.
Okay, so the next question Ihave for you, my audience, is
are there problems with waitingto have a rotator cuff tear, a
rotator cuff repair?
And you know this is a questionthat I brought up to a surgeon
on a podcast that I didpreviously back in in my earlier
(12:21):
days and remember this, I amnot a surgeon, but we know some
of these things.
This is just how it happens.
When you tear your rotator cuff, that rotator cuff if it's a
full thickness tear can retract,okay.
So basically like an elasticthat you stretch out and
somebody cuts one end, it pullsback and recoils and retracts.
So it makes it harder for asurgeon to put back in place.
(12:43):
The longer it stays retracted,the tip of that rotator cuff
tear might start scarring down.
Is that going to heal?
Well, when they put that backin place or when they repair
that?
Will this patient start todevelop some labral and glenoid
erosion?
If the rotator cuff is notdepressing the humerus, then
(13:05):
that humerus is going to startto erode that superior glenoid
and eat out at that labrum andyou basically get this shifting
and this grinding of the jointand will the patient develop
some atrophy which could make itdifficult down the road if they
do have that rotator cuffrepaired to get this rotator
cuff active again and get theperiscapular muscles back on
(13:28):
track.
So these all make it morechallenging and more you know,
for the optimal surgical outcome.
So that's something you need totake into consideration and so
I give some of these scenariosto the patient.
I prefer that the surgeon givethis scenario to the patient,
but again, we don't want toscare the patient into having
surgery.
Okay, because I've seen both ofthese cases.
(13:49):
You know where I've had apatient with a 15-year-old
rotator cuff tear and they haveit repaired and they have an
excellent outcome.
And then I've seen patients whohave the repair right after the
injury and do poorly.
There are so many factors.
You know the surgical repairitself, the technique of the
repair, and you know was there agood purchase of the rotator
(14:09):
cuff?
Is there a good tissueintegrity?
Are you repairing two pieces ofleather together?
Are you repairing wet toiletpaper?
You know patient agecomorbidities, do they have
diabetes?
Are they smokers?
You know all of these thingscan make a huge difference when
you know not having a rotatorcuff repair.
So we don't always know howthis is going to go.
(14:32):
So I have this other patienthere and I don't really I mean,
I could go on, I have yearsworth of patients, but I have
this patient right now.
His name is Al, he's soon to be80 years old, he's extremely
active, he likes to bowl, helikes to fish, um, and he likes
loves to golf.
This guy was a weightlifter andhe could.
I remember him bench pressingover 300 pounds at 65 years old
(14:54):
and he today told me that hecontinues to curl 25 pound
dumbbells on a regular basis andhe does, you know, basically
dumbbell presses with 30pounders and just does his best
in the range that he has.
He just likes, he's alwaysliked to weightlift and so he
(15:15):
just underwent a right CMCarthroplasty.
And he's a bowler, so he can'tbowl with his right hand right
now, but his goal is to be ableto bowl, you know, next winter.
And his left shoulder is is shot, and when I say shot, I mean he
has 0 to 10 degrees of flexion,0 to 10 degrees of abduction.
(15:36):
If I lift him up, he has apositive drop arm test.
He has considerable shoulderhiking.
His external rotation is 2 plusover 5 max.
Internal rotation is 4 over 5.
He has a massive rotator cufftear Passively full range of
motion.
And he does have some arthritisin the shoulder which is
demonstrated through an x-rayMRI.
(15:58):
He has no pain but he has nofunction okay and he wants to
have surgery.
He wants to be able to golfagain and so he's had an
attempted rotator cuff done Iwant to say eight or 10 years
ago and it failed.
They could only partiallyrepair the cuff.
The integrity of the tissue wasawful and it just did not take.
(16:18):
So at this stage of the game heneeds a total shoulder, a
reverse total shoulderarthroplasty, because his cuff
is not good, he has bad tissueintegrity and he has arthritis
in the shoulder.
So he's going to be and he'sotherwise healthy, so he he is
going to do very well with areverse total shoulder
arthroplasty.
So everybody's situation isdifferent and you need to treat
(16:43):
each one of them individuallyand you have to respect what
patients tell you.
So, even though you know it maynot be the best decision, if
they're not in a significantamount of pain and they are
functioning and they can takecare of themselves, then, icing
on the cake you know I have alist of patients in front of me
right now.
I can go through these storiesof you know a Border Patrol
(17:04):
agent who tore his rotator cuff.
He was lined up for surgeryalong with this 80-year-old
Priscilla, who was lined up forsurgery.
Also, both of them came into PTat the same time.
They both did extremely well.
He went on to weightliftinglike he used to do in the past
and continuing on with his workwith no pain, full function.
And Priscilla has 80% of hershoulder function but she's like
(17:28):
I'm not in a lot of discomfortand I can take care of myself
and help my husband and I candrive and I can do whatever I
need to do, happy to not havesurgery.
Okay, so we know that pain is abig driver towards surgery, uh,
but you know a lot of people canhave pain coming from somewhere
else.
So it's very important that ifyou do deter, if you do decide
(17:48):
to treat these folksconservatively and you know they
have rotator cuff tears andmaybe they're they're not
painful then you need to monitorthem often.
You need to make sure theydon't have an underlying nerve
injury like a suprascapularnerve injury or an axillary
nerve injury or something likethat.
A C5 nerve root compression canlook just like a rotator cuff
(18:11):
tear, parsonage, turner syndrome.
I mean we've seen all of thesejust in the last couple of weeks
, and so you need to make surethat they don't have another
underlying condition that causesthem to look like they have a
rotator cuff tear, all right.
So if you do treat themconservatively, monitor them
often, look for some improvement.
You don't want to see regressionin these patients, but if
(18:32):
they're not coming along, it'stime to meet with the surgeon
again and have a conversation on.
You know, do you want to haveless pain and do you want to
have better function, and how doyou increase that chance of
that happening?
So you know patients shouldknow the facts, but they should
not be scared into havingsurgery.
So I have a lot of experiencewith patients who have had
shoulder problems.
I've seen many scenarios andI've seen what works.
(18:54):
I've seen what doesn't work.
But again, like I said earlier,nothing is black and white when
it comes to treating shoulderpatients.
Okay, so I hope you enjoyedtoday's episode.
I know I threw a lot at you.
I know you may not have theanswers to everything.
I love to do online coachingand answer those questions.
You know one-on-one or youbring your patient scenarios to
(19:16):
me.
We have a discussion on how tomanage them better.
Maybe we go through an anatomyreview.
We talk about anythingorthopedic, pretty much from
evaluating patients to how toconnect with shoulder surgeons
and other specialists out therewho you want to work with.
If you are interested in a liveshoulder course, I'm going to
be giving one in May of 2025 inAuburn, maine.
(19:36):
So you just check out the linksin the description and you can
click on that if you want moreinformation, such as the agenda
or the location, the time andthings like that.
So we do have a few spotsavailable.
If you're interested, feel freeto jump in.
I'd love to meet you and talkshoulders If you want to see
some real patients with realdiagnoses I know not all of them
(19:58):
are in 4k, some of them are oldWe've had our YouTube channel
going for 13 plus years but youcan take a look at some of these
patients with some of thesediagnoses of reverse total
shoulders, rotator cuff repairs,major tears, bicep ruptures,
you name it.
We have it.
Just Google Paul Marquis andthe diagnosis and it'll pop
(20:19):
right up or hit the links in theshow notes and that'll take you
right over there and I hope youenjoy those.
But with that being said, folksbe kind to each other and take
care.
Hello everyone and welcome to episode 374 of the
OrthoEvalPal podcast.
I am your host, Paul Marquis,and I'm a physical therapist.
Today we're going to be talkingabout the painless rotator cuff
tear and how to manage it.
We're going to be talking aboutwho's at highest risk of
rotator cuff tears.
We'll talk about the clinicalexam versus MRI, pain versus
function advice we might giveour patients, you know, when
(00:23):
trying to decide if surgery isappropriate, and so much more.
But before we get started today, I just want to mention our
sponsors.
We have range master.
Range master is known for theirshoulder rehab equipment.
They offer products fromshoulder wands to finger ladders
, overhead pulleys to shoulderrehab kits.
Range master is your one-stopshop to help with the treatment
of frozen shoulders, post-oprotator cuff repairs, total
(00:46):
shoulder and reverse totalshoulder replacements, and so
much more.
If you'd like to get a freesample of Rangemaster's Blue
Ranger pulley system, just emailjim at myrangemastercom and add
OrthoEvalPal in the subjectline.
Now we also have MedCorpprofessionals.
Now I know the folks at MedCorpPersonally.
(01:08):
They are locally owned and afamily-operated medical supply
company.
They carry everything fromradial pressure wave units to
traction devices, resistancebands to compression garments.
Most impressively, though, istheir customer service.
It's second to none.
I know these folks personally.
They are great to work with anddo an awesome job at getting
the right products to you and toyour patients at a very
efficient time.
They are second to none.
(01:29):
If you're looking for medicalproducts for your clinic or
products for your patients, goto wwwmedcorprocom and if you
use coupon code OEP10, you canget $10 off a Sondra cervical
traction unit and if you usecoupon code FIRSTTIME10, you can
get $10 off your first order atMedcor on other products.
Welcome back everyone.
(01:51):
Oh boy, is this going to be alittle snowball episode?
I'll tell you, and you know,it's one of those episodes where
I have this idea I want to talkabout this.
It's like simple.
I'm like this is gonna be likea 10 minute episode and it just
rolls and rolls and rolls and Ijust want to keep going with
this and I just want to get intomy life course.
I'm going to be giving in acouple of months and just go on
(02:13):
with this stuff.
Um, so where do we even start?
Okay, I want to talk aboutrotator cuffs today.
And we are.
We're going to a place wherenothing is black and white today
, Okay, and you may get donewith this episode and say I
can't believe I listened to this, Like I don't know if I got the
answers I was looking for whenI got into this episode.
(02:36):
There's going to be a lot ofgray area here, but one thing
you need to remember is thatevery single patient who comes
in with a rotator cuff problemor a shoulder problem is
different than the previous onethat you saw.
I tell patients this all thetime.
I could have a hundred rotatorcuff tear patients standing side
by side.
They will all presentdifferently as far as active
(02:56):
range of motion, passive rangeof motion, pain levels and
function.
They will look different and Iwill treat every single one of
them differently, Okay.
So if you think you're going tocome to a course and you're
going to get the one answer foryour rotator cuff tear patients,
you're at the wrong course.
Okay, we need to teach you howto individualize, how to manage
(03:19):
these people.
Okay, Cause they're all sodifferent.
I mean, think about it.
There are two over 250,000rotator cuff repairs done every
year in the United States.
40% of people over 60 years oldhave a rotator cuff tear.
Okay, Now, that could besymptomatic or asymptomatic.
Now, if you take 100 peoplethat don't have shoulder
(03:42):
problems and you MRI them or doa diagnostic ultrasound, you'll
find that 40% of those peoplewill have partial rotator cuff
tears and up to 46% will havefull thickness rotator cuff
tears, but they're asymptomatic.
They wouldn't even know thatthey had it.
Okay, so I can't even, you know,try to figure out how many
(04:04):
patients with rotator cuffs I'veseen over my 33 years of being
a PT.
I know that, like if I were tothrow all shoulders together, I
just couldn't even put a numberon it.
It's astronomical, From frozenshoulders to impingement, to
proximal bicep issues, to labraltears, you name it.
But we do see a tremendousnumber of rotator cuff tear
patients.
I think we had like seven oreight in the clinic the other
(04:25):
day, you know, pretty much allin one morning amongst the
therapist and myself who were inthat clinic.
So I've seen a lot of them.
One thing I'm going to try toinstill today is, you know,
treat everybody individually ifpossible.
So what I want to do today, too, is I want to discuss my
thought process on how I managethese patients who have, more
(04:45):
specifically, a non-painfulrotator cuff tear.
Okay, so I'm going to starthere with a patient presentation
and it's a 54-year-old male andit's not me, although I do have
a small rotator cuff problemwhich I'm working on right now,
but it's coming along nicely.
So, but we do have a 54 yearold male who I bump into at the
(05:10):
redemption center, knew this guyfrom a long time ago.
I'm like, hey, how you doing?
And he's like great.
But I just said I just recentlyhurt my shoulder and I'm like,
oh really, no kidding.
I said try to lift your arm.
And he couldn't like lift hisarm off his side.
It was crazy.
So I suggested he come see me.
I took a look at him.
I was 100% sure he had arotator cuff tear and so I set
(05:30):
him up with an orthopedicsurgeon and he met with this
surgeon and the surgeon says youknow, have you ever had a
rotator cuff tear in the past?
And he said yes.
He says well, he says I suspectthat I did.
He says well, he says I suspectthat I did.
(05:51):
He said I had three episodesthat hurt my shoulder, but each
time I did it I lost more andmore function.
And so, you know he, thesurgeon, said well, you know,
you have a MRI diagnosed rotatorcuff tear.
You clinically look like youhave a rotator cuff tear, we can
do surgery anytime you want.
And so he came to me and said Ireally need your opinion on
this if I should have this ornot.
And so his worry is that he thelength of time to recover and
the pain associated with thesurgery.
(06:12):
And he reports to me that, eventhough he can't use his arm
very well, he doesn't have anypain no nighttime pain, no
daytime pain.
I ask him about pain withfunction, he says he doesn't do
much.
He uses a computer at his work,he's a minister on the side and
he just doesn't do a lot ofphysical activity around the
(06:32):
house.
He says I I can do everything Ineed to do, I can take care of
myself and I just don't havethis pain and I don't really
want to undergo.
He said I've seen people whohad rotator cuff repairs done
before and they're in severepain for a long time.
They're in a sling, you know,and they're really out of
commission and whatnot.
So let me just paint you thephysical picture of this
(06:54):
gentleman.
He has active flexion of aboutzero to a hundred degrees,
abduction zero to 80 degrees,external rotation to about 45
degrees.
This is all actively Internalrotation to about 60 degrees.
Now his passive range of motionis significantly better, but he
does have a little bit ofcapsular tightness at the end
(07:15):
ranges, and he should right,Because he hasn't been lifting
his arm overhead, he hasn't beenreaching way behind him to put
his jacket on, because he justcan't move that arm that much
and so he just doesn't go there.
So we expect his capsule to betight.
All right Now.
Manual muscle testing is prettyawful.
Flexion abduction three minusover five.
(07:36):
Obviously you can't even get itto full range of motion.
External rotation two plus tothree minus over five max.
Now when I resist his flexionabduction, external rotation, he
has a significant shoulder hike.
Internal rotation is about 4plus over 5.
He has very poor humeral headdepression.
(07:56):
His cuff is not depressing hishumeral head whatsoever.
So the patient asks me what doI do?
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Speaker 1 (08:41):
Well, folks?
Number one is it my place totell him what he should do or he
shouldn't do?
Now I know he comes to me.
He says listen, I know you havea lot of experience.
I totally trust you.
You have great rapport withyour patients and great outcomes
.
And I'm not patting myself onthe back.
I'm telling you what thepatient is telling me and I've
seen a lot of things and I'velearned a lot of things when I
(09:03):
was a young therapist and Ireally was able to sort out a
lot of these things a little biteasier.
But oftentimes there is nodefinitive answer.
So is it my place to tell thispatient yeah, you should go
ahead and have your rotator cuffrepaired, because we know
there's a high risk that you'regoing to develop osteoarthritis
(09:23):
of your shoulder early and thatcould be a problem.
Maybe he'll develop someatrophy, some weakness, maybe
later on develop some pain.
Number two do we tryconservative treatment and see
what happens, or do we just waitand see how this transpires, if
he goes on with his everydaylife and maybe we check him out
(09:46):
in a month or two months and andsee how it's?
It's going okay.
So he's 54 years old, he has noarthritis.
He doesn't have pain andfunctionally he can get along.
So what do we do?
So my question to you is do allrotator cuff tears need to be
repaired?
And the answer is no.
(10:08):
I have a patient now who came inwith he was in terrible shape
with a torn rotator cuff and alabrum.
He opted to try PT reluctantly.
His doctor said, well, let'stry some physical therapy.
And obviously when I saw him hehad a torn cuff, he had issues
with his labrum, he hadsignificant loss of motion.
He first, when he first tore it, he had a big fall and he said
(10:31):
his pain was severe.
For a day or two he could notlift his arm and then for about
a week it got better and betterand better and then he could
start to lift his arm a littlebit better and then it just got
progressively worse after that.
So he came to see me.
I want to say it was four orfive months after the onset of
this injury and he was justmiserable.
(10:53):
And I said I educated him aboutyou know what a rotator cuff
tear is, what a labral tear is,and that I've had many patients,
even in the last couple ofyears, who have complete rotator
cuff tears who get better andthey're comfortable and they're
fine.
But if they don't get better,then we have the option of
surgery.
So he opted for physicaltherapy reluctantly, and within
(11:15):
two visits he was significantlyshowing improvement in regards
to his function.
And what had happened was hehad developed a frozen shoulder
after the injury.
So not only did he tear hisrotator cuff in his labrum, but
he developed this frozenshoulder.
That that's why he got betterat first, and then he
progressively got worse and thearm got stiffer.
So he managed his adhesivecapsulitis and guess what?
(11:37):
He started to develop betterand better range of motion.
He's 95% better now.
I saw him just a couple ofweeks ago and I'm going to do a
check on him in another monthjust to see how he's doing.
But he told me I cancomfortably live the rest of my
life like this.
He says I don't want to havesurgery, I'm very functional,
I'm a pharmacist, I also do alot of work outdoors on the side
(11:58):
and I can do everything I wantto do.
Okay, so the next question Ihave for you, my audience, is
are there problems with waitingto have a rotator cuff tear, a
rotator cuff repair?
And you know this is a questionthat I brought up to a surgeon
on a podcast that I didpreviously back in in my earlier
(12:21):
days and remember this, I amnot a surgeon, but we know some
of these things.
This is just how it happens.
When you tear your rotator cuff, that rotator cuff if it's a
full thickness tear can retract,okay.
So basically like an elasticthat you stretch out and
somebody cuts one end, it pullsback and recoils and retracts.
So it makes it harder for asurgeon to put back in place.
(12:43):
The longer it stays retracted,the tip of that rotator cuff
tear might start scarring down.
Is that going to heal?
Well, when they put that backin place or when they repair
that?
Will this patient start todevelop some labral and glenoid
erosion?
If the rotator cuff is notdepressing the humerus, then
(13:05):
that humerus is going to startto erode that superior glenoid
and eat out at that labrum andyou basically get this shifting
and this grinding of the jointand will the patient develop
some atrophy which could make itdifficult down the road if they
do have that rotator cuffrepaired to get this rotator
cuff active again and get theperiscapular muscles back on
(13:28):
track.
So these all make it morechallenging and more you know,
for the optimal surgical outcome.
So that's something you need totake into consideration and so
I give some of these scenariosto the patient.
I prefer that the surgeon givethis scenario to the patient,
but again, we don't want toscare the patient into having
surgery.
Okay, because I've seen both ofthese cases.
(13:49):
You know where I've had apatient with a 15-year-old
rotator cuff tear and they haveit repaired and they have an
excellent outcome.
And then I've seen patients whohave the repair right after the
injury and do poorly.
There are so many factors.
You know the surgical repairitself, the technique of the
repair, and you know was there agood purchase of the rotator
(14:09):
cuff?
Is there a good tissueintegrity?
Are you repairing two pieces ofleather together?
Are you repairing wet toiletpaper?
You know patient agecomorbidities, do they have
diabetes?
Are they smokers?
You know all of these thingscan make a huge difference when
you know not having a rotatorcuff repair.
So we don't always know howthis is going to go.
(14:32):
So I have this other patienthere and I don't really I mean,
I could go on, I have yearsworth of patients, but I have
this patient right now.
His name is Al, he's soon to be80 years old, he's extremely
active, he likes to bowl, helikes to fish, um, and he likes
loves to golf.
This guy was a weightlifter andhe could.
I remember him bench pressingover 300 pounds at 65 years old
(14:54):
and he today told me that hecontinues to curl 25 pound
dumbbells on a regular basis andhe does, you know, basically
dumbbell presses with 30pounders and just does his best
in the range that he has.
He just likes, he's alwaysliked to weightlift and so he
(15:15):
just underwent a right CMCarthroplasty.
And he's a bowler, so he can'tbowl with his right hand right
now, but his goal is to be ableto bowl, you know, next winter.
And his left shoulder is is shot, and when I say shot, I mean he
has 0 to 10 degrees of flexion,0 to 10 degrees of abduction.
(15:36):
If I lift him up, he has apositive drop arm test.
He has considerable shoulderhiking.
His external rotation is 2 plusover 5 max.
Internal rotation is 4 over 5.
He has a massive rotator cufftear Passively full range of
motion.
And he does have some arthritisin the shoulder which is
demonstrated through an x-rayMRI.
(15:58):
He has no pain but he has nofunction okay and he wants to
have surgery.
He wants to be able to golfagain and so he's had an
attempted rotator cuff done Iwant to say eight or 10 years
ago and it failed.
They could only partiallyrepair the cuff.
The integrity of the tissue wasawful and it just did not take.
(16:18):
So at this stage of the game heneeds a total shoulder, a
reverse total shoulderarthroplasty, because his cuff
is not good, he has bad tissueintegrity and he has arthritis
in the shoulder.
So he's going to be and he'sotherwise healthy, so he he is
going to do very well with areverse total shoulder
arthroplasty.
So everybody's situation isdifferent and you need to treat
(16:43):
each one of them individuallyand you have to respect what
patients tell you.
So, even though you know it maynot be the best decision, if
they're not in a significantamount of pain and they are
functioning and they can takecare of themselves, then, icing
on the cake you know I have alist of patients in front of me
right now.
I can go through these storiesof you know a Border Patrol
(17:04):
agent who tore his rotator cuff.
He was lined up for surgeryalong with this 80-year-old
Priscilla, who was lined up forsurgery.
Also, both of them came into PTat the same time.
They both did extremely well.
He went on to weightliftinglike he used to do in the past
and continuing on with his workwith no pain, full function.
And Priscilla has 80% of hershoulder function but she's like
(17:28):
I'm not in a lot of discomfortand I can take care of myself
and help my husband and I candrive and I can do whatever I
need to do, happy to not havesurgery.
Okay, so we know that pain is abig driver towards surgery, uh,
but you know a lot of people canhave pain coming from somewhere
else.
So it's very important that ifyou do deter, if you do decide
(17:48):
to treat these folksconservatively and you know they
have rotator cuff tears andmaybe they're they're not
painful then you need to monitorthem often.
You need to make sure theydon't have an underlying nerve
injury like a suprascapularnerve injury or an axillary
nerve injury or something likethat.
A C5 nerve root compression canlook just like a rotator cuff
(18:11):
tear, parsonage, turner syndrome.
I mean we've seen all of thesejust in the last couple of weeks
, and so you need to make surethat they don't have another
underlying condition that causesthem to look like they have a
rotator cuff tear, all right.
So if you do treat themconservatively, monitor them
often, look for some improvement.
You don't want to see regressionin these patients, but if
(18:32):
they're not coming along, it'stime to meet with the surgeon
again and have a conversation on.
You know, do you want to haveless pain and do you want to
have better function, and how doyou increase that chance of
that happening?
So you know patients shouldknow the facts, but they should
not be scared into havingsurgery.
So I have a lot of experiencewith patients who have had
shoulder problems.
I've seen many scenarios andI've seen what works.
(18:54):
I've seen what doesn't work.
But again, like I said earlier,nothing is black and white when
it comes to treating shoulderpatients.
Okay, so I hope you enjoyedtoday's episode.
I know I threw a lot at you.
I know you may not have theanswers to everything.
I love to do online coachingand answer those questions.
You know one-on-one or youbring your patient scenarios to
(19:16):
me.
We have a discussion on how tomanage them better.
Maybe we go through an anatomyreview.
We talk about anythingorthopedic, pretty much from
evaluating patients to how toconnect with shoulder surgeons
and other specialists out therewho you want to work with.
If you are interested in a liveshoulder course, I'm going to
be giving one in May of 2025 inAuburn, maine.
(19:36):
So you just check out the linksin the description and you can
click on that if you want moreinformation, such as the agenda
or the location, the time andthings like that.
So we do have a few spotsavailable.
If you're interested, feel freeto jump in.
I'd love to meet you and talkshoulders If you want to see
some real patients with realdiagnoses I know not all of them
(19:58):
are in 4k, some of them are oldWe've had our YouTube channel
going for 13 plus years but youcan take a look at some of these
patients with some of thesediagnoses of reverse total
shoulders, rotator cuff repairs,major tears, bicep ruptures,
you name it.
We have it.
Just Google Paul Marquis andthe diagnosis and it'll pop
(20:19):
right up or hit the links in theshow notes and that'll take you
right over there and I hope youenjoy those.
But with that being said, folksbe kind to each other and take
care.
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