The Bone Whisperers

Rotator Cuff Tears & Repairs

Episode Summary

The latest advances in shoulder repairs for rotator cuff injuries

Episode Notes

Dr. Dennis Cardone and Dr. Joseph Zuckerman from NYU Langone Orthopedics discuss the latest advances in diagnosing and treating rotator cuff and shoulder injuries. From non operative approaches, to advances in surgical repairs and recovery, hear the latest from the world's best orthopedic surgeons.

Episode Transcription

Narrator: SiriusXM presents an NYU Langone Orthopedics podcast. Orthopedics is just very important to the population in this country. Its ability to restore patient function. Problems related to cartilage, to someone who has more advanced forms of arthritis.  Getting people back to their activities and the things that they like to do. Featuring NYU's experts in the field of Orthopedics trying to figure out that problem before it even is a problem. Problems with solutions. Well beyond physical therapy, to conservative pain management, to surgery. The best medical minds now come together. Applying all of our minds to solve these problems. We're here to get people feeling better so they can get back to their lives. And that's really what we try and accomplish. These are the Bone Whisperers.

Dr. Dennis Cardone: Hello, and welcome to the Bone Whisperer podcast. I'm, um, Doctor Dennis Cardone, and I'm joined by my co host, Doctor Joseph Zuckerman, and both from the Department of Orthopedic Surgery at NYU Langone Health. And Doctor Zuckerman, of course, the, uh, chairman of the department of orthopedic surgery and a renowned shoulder surgeon. And we're talking about rotator cuff - rotator cuff problems, and maybe when surgery, when not surgery, and treatment and problems related to rotator cuff. So let me start the ball rolling and say maybe, Doctor Zuckerman, if you would define for our listeners - rotator cuff.

Dr. Joseph Zuckerman: Well, Dennis, I think that's exactly the right place to start, because people need to have an understanding of the anatomy of the problem. A lot of people, uh, my patients, I hear them refer to as the rotator cup, uh, the rotating cuff, you know, various things. Rotor cuff, rotor cuff, that's another thing which sounds like a part of your car, right? But the rotator cuff is a group of four muscles and tendons that originate from your shoulder blade or the scapula as muscles, and they extend out to the side, towards your shoulder, towards the upper arm bone called the humerus. And they attach in a cuff to, uh, the upper part of the humerus. And together they are responsible for many of the shoulder motions that you can perform. So there are four rotator cuff muscles. They name the subscapularis, that's the one in front. The supraspinatus, which is the one on top, the infraspinatus, which is the one just behind it. And the most posterior, or one towards the back is the teres minor. The one that seems to get the most press is the supraspinatus because that is the one that's most often injured or torn or involved in various types of, uh, injuries or overuse type situations.

Dr. Dennis Cardone: What makes the rotator cuff so special? I mean, when you think about, it, so fine four muscles and tendons that do just about everything he has the shoulder to do. But we could define muscle and tendons that sit around the ankle, that sit around the knee joint, that sit around the elbow, but certainly don't get the same attention, maybe don't have near the type problems and near the surgical interventions or other interventions. So the rotator cuff's really special.

Dr. Joseph Zuckerman: Well, it is. And part of that is because of the joint that is associated with what we know is the shoulder - which is technically called the glenohumeral joint because it's the joint between the glenoid or the socket of the shoulder and the upper arm bone of the humerus - is the most mobile joint in the body. In other words, you can move your shoulder around in more directions to a greater degree than any other joint. So whereas my colleagues who are foot and ankle specialists will tell me that, oh, the ankle is very complex joint because it does all these things. And that's true. It is, but it doesn't have anywhere near the range of motion that a shoulder does, because even the most inelastic or stiff people, well, can still move their arm, their shoulder, their arm around in a, uh, almost 180 degree circular motion. Now, in order to do that, you need the rotator cuff muscles and the associated muscles around the shoulder to work in concert with each other, in conjunction with each other in a coordinated fashion. But it also puts a lot of stress on the rotator cuff because of the degree of motion and the number of activities that it's performing every day.

Dr. Dennis Cardone: So people say that joint, what do you use? You use the golf ball on the tee, you know, because it does have so much motion and a joint that there's not much bony joint stability. It really is a soft tissue that gives it stability.

Dr. Joseph Zuckerman: Yes. And I guess the analogous joint in the lower extremity is supposed to be the hip. But the hip is truly a ball in a socket. The shoulder is more or less a ball on a dish, a relatively flat dish, which allows the ball to move around in all different directions. Now, that's the good news. The good news is that it allows such a great range of motion. The somewhat bad news is that the shoulder is also the joint, and the body that's most commonly can get dislocated from injury and such. And we call that instability. So that's the downside of it. But overall, when you think about what we do with our shoulders and our arms, it's a great advantage to us.

Dr. Dennis Cardone: So probably when a patient comes in and it's a rotator cuff problem or a shoulder problem, even probably before you even put your hands on the patient, uh, a 15 year old versus a 40 year old versus a 70 year old with shoulder pain. And let's say if you already knew it was a rotator cuff problem, because, interesting, it could be a 15 year old with a rotator cuff problem, a 45 year old, a 75 year old, whatever it is. But what's different about those age groups and rotator cuff problems? So what do you think about?

Dr. Joseph Zuckerman: Well, I would say that classically and most typically, rotator cuff problems are much more common in adults and older adults, even as you get progress into the sixties and seventies, most people would say it's a product of overuse that occurs through many years of activity. Now, there is a group of patients who present much younger, in their twenties, maybe, uh, even earlier than that, and those are associated with athletic injuries. Everybody reads in the newspaper about baseball players that develop rotator cuff problems, rotator cuff inflammation. Uh, and they need to be shut down for a while because of it. Well, those are very high level activities for the rotator cuff in which they're subjected to a lot of stress. So that's a specific risk group for rotator cuff problems. And then there's probably the group, a little older, thirties, forties, getting into the fifties, in which rotator cuff problems become more of an overuse situation, maybe from athletics and recreational sports, but sometimes it's associated with the jobs you have.

Dr. Dennis Cardone: I had a patient today, 36 year old pilot, non dominant arm, right arm, and he said when he's in the cockpit flying, he's constantly hitting switches overhead when flying. So an interesting overhead activity that you wouldn't think about even for a pilot, right?

Dr. Joseph Zuckerman: You wouldn't think about it for a pilot because they are in relatively confined spaces, so the amount of reaching is relatively limited. But I think about it in electricians who were, uh, constantly working with their arms, overhead, painters working with their arms overhead. And I've even seen a number of hairdressers, hairstylists that also work with their arms at the shoulder level and above. So there are occupational hazards that can predispose the rotator cuff problems.

Dr. Dennis Cardone: 45 year old woman, man, you diagnose a rotator cuff problem. Is that a rotator cuff, tendonitis, a tendinosis, is that a tear? What does it mean? And how do you even differentiate one from the other?

Dr. Joseph Zuckerman: So all rotator cuff problems are not created equal. There's a, I would like to say a continuum of things. So keep in mind the rotator cuff is a tendon. So let's skip significant traumatic injuries. People that fall significantly, or in a car accident, they have major trauma to the shoulder. Let's skip that for right now. Let's discuss the more common one, which relates to activity related symptoms. Overuse. The rotator cuff is a tendon. If you look at the anatomy of the shoulder, there's the humeral head that forms part of the glenohumeral joint. The shoulder capsule is on top of the humeral head. The rotator cuff tendon, whether it be the supraspinatus or the infraspinatus or the others, is intimately associated with the capsule or the envelope of the shoulder joint. On top of the tendon is the bursa. Now, what is a bursa? The bursa is a type of tissue that's placed in its position to enhance gliding. It secretes a certain amount of fluid to make sure the tissues can glide smoothly. And that has to happen because if you put your hand on top of your shoulder, the first thing you feel is the bone. The bone there is called an acromion. That's a part of the shoulder blade. So the bursa is there to help the excursion or the movement of the rotator cuff tendons underneath that bony arch that's there. So in that context, you have first thing that will happen with overuse is inflammation. Things will get inflamed. They'll get swollen, for lack of a better word. So that's why a lot of people say things like, I have bursitis. Specifically, they may say, I have subacromial bursitis. Subacromial meaning underneath the acromion, bursitis. So the bursa is inflamed. In reality, it's hard to tell the difference between bursitis or tendinitis, which would be inflammation of the rotator cuff tendon, which lies right underneath the bursa. So the first thing you see is inflammation, swelling - itis. Right. That's the body's ability to react to injury, is inflammation. So the first thing is some degree of bursitis or tendinitis in the area of the rotator cuff.

Dr. Dennis Cardone: So the rotator cuff's inflamed like a tendinitis, or maybe there's even scar tissue or partial tearing, tendinosis. So does that matter that 45 year old tendinitis versus tendinosis, in other words, inflammation versus maybe partial tearing in your initial treatment or how do you approach a rotator cuff?

Dr. Joseph Zuckerman: Well, uh, initially, when you evaluate somebody, it's hard to tell the difference between tendinitis and what we call tendinosis. Tendinitis means that the tendon is inflamed. Tendinosis means that there's some structural compromise of the tendon. In other words, if the tendon is a thick sheet of carpet, all right, let's say. Part of it is now disrupted, a little worn away and such. Now, when I examine a patient in the early stages, I can't tell the difference between the two from a clinical perspective, from an examination. It matters because I think inflammation alone is more easily addressed than a structural compromise of the tendon. But if you think about the thickness of the tendon as being, let's say, quarter of an inch or three eight of an inch thick, minor changes in that thickness are not going to really have a long term effect. But as tendinosis progresses and becomes more structurally impaired, that's when you can progress to more significant tears, which are commonly referred to as partial tears. And as that gets worse, you can have full thickness tears. Now, oftentimes, when I explain to patients the difference between partial tears and full thickness tears, I, uh, used the analogy of a pair of jeans. Now, in previous years, before we started buying ripped jeans with large holes in it, we would buy a structurally intact pair of dungarees, jeans, that you'd wear, and they were your favorite jeans. And over time, you would see the area just above the knee would start to get thin, and it would get worn out. So as that cloth wears away, that's the equivalent of a partial thickness tear. As soon as you can see your skin through the jean cloth, that's a full thickness tear. Now, as you can imagine, a full thickness tear can be very small, which is much less significant than a large full thickness tear, which would be the equivalent of what people are now paying for when they buy their jeans. Right. So it's a whole, it's a whole different fashion era, but that's what it is. That's a full thickness tear. So if you start with inflammation or tendinitis, bursitis, you can progress to tendinosis, and that's some degree of structural, uh, compromise, to a partial thickness tear of the rotator cuff, to a full thickness tear. And as that progresses, most patients will become, I'd say, more symptomatic. But not every patient. That's what's really confusing about the rotator cuff.

Dr. Dennis Cardone: So your patient comes in, and you're thinking, rotator cuff problem, what is it on your physical examination diagnosis that maybe leads you down that pathway? Maybe even in history. What's a classic history and diagnosis? Physical examination findings.

Dr. Joseph Zuckerman: So all the things I've just told you about inflammation and tendinosis and partial thickness tearing, all those are important diagnostic categories. However, arriving at a true diagnosis is a basic element of what we do in orthopedic surgery or medicine. The backbone of diagnosis is obtaining a history from the patient, listening to them, and says, when did this start? What, uh, makes it worse, what makes it better? What treatment have you had? When is it most painful? When it is less painful? You take that history, and then you do your physical exam, looking for specific findings that may be related to the rotator cuff or it may be related to something else. I think that a properly done history and physical exam will diagnose the problem with reasonable certainty 90% of the time. And then you add in what we call imaging studies, which for us would be standard x rays of the shoulder and MRI. I mean, unfortunately, most people, and even physicians, they think there's a rotator cuff problem, they kind of gloss over the history and physical, and they say, okay, let's get an MRI. But the MRI is only as important and meaningful as how you integrate it into what you've gleaned from the patient, from the history and the physical. Because MRIs are just that. It's just a static representation, whether that represents the true problem that they have, that's where the physician or the orthopedic surgeon comes in. So when somebody tells me what their symptoms are, they say, well, when I lift my arm overhead, it really hurts when I get to the shoulder level and above, that's classic for rotator cuff problems. Or when they say, you know, I'm pretty good during the day, but at night, I just can't sleep. It's worse at night. Again, that's typical for rotator cuff problems. So those are the things you expect.

Dr. Dennis Cardone: Which is really quite interesting, that nighttime pain. Right? Because, uh, I don't know if there's ever really been a good, just interestingly, why rotator cuff is specific at night? I mean, many theories, but nothing definitive.

Dr. Joseph Zuckerman: Yes, many theories, but they're really just educated guesses, uh, this whole thing. Yeah. And when you examine somebody, there are certain classic findings. You expect to identify pain with certain positions of range of motion. Pain when lowering the arm may be more problematic. Sometimes you'll see limitation of range of motion, but that's usually later on, after they develop some stiffness. And then there are certain tests that we may perform or certain maneuvers, something called the impingement test, the impingement signs, in which you stress the shoulder in a certain position to provoke the symptoms to help you confirm the diagnosis. Uh, and then sometimes we'll inject the shoulder with a local anesthetic into the area of the rotator cuff to help confirm the diagnosis.

Dr. Dennis Cardone: Now, patients probably always say, Doctor Zuckerman, why are you wasting my time and getting an x ray? Can't you just go straight to the MRI? Why are you even bothering an x ray? You probably can't see rotator cuff on x ray, right?

Dr. Joseph Zuckerman: You cannot see the rotator cuff on x ray directly. However, uh, you can see a lot of other things that may be causing symptoms. For example, certain things masquerade as rotator cuff problems. I've seen patients with completely normal rotator cuff who had every symptom that you would think is associated with a rotator cuff. But what did they have? They had a pinched nerve in their neck that was giving them referred pain to the shoulder. I've seen patients that have had rotator cuff surgery because it wasn't recognized that was a neck problem. I've also seen patients that had neck surgery when the surgeon didn't recognize it was a rotator cuff problem. So as much as we have to rule in, meaning make the diagnosis, we also have to rule out other diagnoses. And sometimes you get an x ray of somebody that you think has a rotator cuff problem, and it will show significant arthritis. Well, that's a source of pain in and of itself. And there are some relatively less common problems around the shoulder that you may see on x ray. Right? And it's true, you may see it on MRI, but an x ray is a simple way to go about it. And sometimes when I get an x ray, there's no need to get an MRI.

Dr. Dennis Cardone: And you can sometimes even make a diagnosis of a full rotator cuff tear on an x ray, right? There are certain findings, uh, on that x ray.

Dr. Joseph Zuckerman: Yes, I mean, there are. There are findings, uh, on a standard x ray that you could see that suggest a significant rotator cuff problem. There's something called rotator cuff arthritis that has a classic appearance, and that's quite evident on an x ray. You don't need an MRI or anything to diagnose that. But when we think about the differentiation between inflammation and partial tearing and full thickness tearing, the MRI was absolutely a major advance and our ability to see the exact anatomy. In the old days, before MRI, we had x ray, but we also had something called an arthrogram. We would inject the patient's shoulder with a dye to see if it leaked out of the joint. That would diagnose a rotator cuff tear, a, uh, full thickness tear. But it didn't tell us anything about the exact location or the size or the extent of the degeneration around the torn area. MRI gives us all that information and more. It's really been quite an advance.

Dr. Dennis Cardone: Even ultrasound now, in some cases is really making its place into rotator, uh, cuff and shoulder problems as a diagnostic tool.

Dr. Joseph Zuckerman: Ultrasound is probably underutilized when it comes to the shoulder because you have to be a very good ultrasonographer to really identify the anatomy or the changes around the shoulder. Many radiologists are not as skilled at that, and let's face it, it's easier just to order an MRI because the skill is in the machine initially - of course, the skill is also in the interpretation of the images - but mostly it's a machine. But you're absolutely right, Doctor Cardone ultrasound is an important modality that should be utilized more.

Dr. Dennis Cardone: So when do you get the MRI? Because you're right, there are so many times and patients always, you know, rightfully so, patients don't know, and I think they always need an MRI, need an MRI, need an MRI. So when does MRI come up in your algorithm? When do you usually go to MRI?

Dr. Joseph Zuckerman: So, in my own practice, if I see a patient who I am concerned that they've got a significant tear of the rotator cuff - in other words, they have trouble lifting their arm and a limited range of motion, weakness - then I won't get an MRI earlier. Because if that case, if there's significant tearing, a full thickness tearing in a patient who's active, working, doing a lot of things that may be a reason for early surgery. But otherwise, in a patient that presents with progressive symptoms, use some, maybe anti inflammatory medication, If it’s not getting better, I will take a standard x ray, make my clinical diagnosis. I'll treat them either with medication, sometimes an injection into the area of an anti inflammatory, like steroids. And then if the pain doesn't get better, or recurs right at that point, I'll get the MRI, because then I want more information. Many people you see with rotator cuff problems respond to medication, therapy to a certain extent, if they're somewhat stiff or injections and you don't see them again. 

Dr. Dennis Cardone: Take an over-40 year old. It's not that typical to see a normal MRI. But it doesn't necessarily say, well, you've got such and such tear, just like you said, a partial tear. But it still leads you down, potentially that physical therapy, injection, anti inflammatory course versus at full tear.

Dr. Joseph Zuckerman: There's no doubt that an MRI is a diagnostic modality that requires a clinician to integrate those findings with what they found on history and physical exam. MRI can be the proverbial true-true and unrelated. Yes, there's a partial thickness tear, but that's not what's causing the symptoms. The symptoms are coming from a pinched nerve in the neck or arthritis of the acromioclavicular joint or something else. So you always have to correlate what you see on the MRI. That's why there's a tendency to over-read or over interpret the MRI without paying careful attention to the symptoms.

Dr. Dennis Cardone: It's interesting because pain generators, especially, you know, how many times, uh, I'll see a 40 something, a 50 something MRI says labrum tear. And oftentimes, it'd be interesting to hear your thoughts, how often is a labrum tear, the symptomatic problem in someone over the age of 40? Or how much is it rotator cuff or a biceps tendon intimately related to the rotator cuff?

Dr. Joseph Zuckerman: When I give talks on shoulder problems, I have one slide that's a copy of an MRI report. And under the final line where it says impression, it says normal MRI of the shoulder. That's the only time I've ever seen that. Because basically the imaging and the detail is so good. The radiologist, who doesn't really have the benefit of seeing the patient, identifies every anatomic abnormality or variation that's there, whether it's relevant or not. And because in our medical record, the patients get copies of everything, we spend a lot of time explaining to them what this means, why it's important, or why it's not important. So you really need to make sure you interpret an MRI findings in the context of the patient. And that's really most important because a lot of the information is not relevant. So apropos to what you said, a labral tear in a 65 year old or a 50 year old - I expect to see that. That's a wear and tear problem. It has nothing to do with their symptoms, for the most part. Different than a 22 year old baseball player, a pitcher, who presents with that finding where it may be quite significant.

Dr. Dennis Cardone: So rotator cuff tears: Partial tear, sounds like absolutely treat them initially non-surgical. So what about your full tear? We talk about full tears - complete tears with maybe even like, a rubber band where the tendon retracts or moves backward. So the translation of all this is, what are your indications for surgery for a rotator cuff?

Dr. Joseph Zuckerman: Well, it's interesting what you say, differentiating between partial tears and full thickness tears. Just let me clarify one thing - all partial thickness tears are not created equal. Let's go back to the jeans . If 90% of the jeans are worn away, you've only got 10% left. That tendon's not going to function very well because every time you pull on it with the muscle, it's going to hurt. So sometimes there are partial thickness tears that can be quite symptomatic and require repair. The classic indication for rotator cuff surgery are people with full thickness tears in which there's a complete disruption of some portion of the tendon, usually right where it attaches to the bone. Those can be small tears or medium, uh, or larger tears. Now, the analogy that you just gave about a rubber band, well, that's what a muscle and tendon is. Every time the muscle contracts, it pulls on the tendon. So you can imagine if you've got a hole in that tendon or a tear, every time you keep pulling on it, over time, that tear is going to get bigger and bigger. Gradually, sometimes faster, uh, rather than slower, but that becomes a problem. Plus, if you're pulling on a torn tendon, that in and of itself can cause pain because the patient is trying to do certain things that the tendon just can't accommodate to. So in general, full thickness tears are the most common reason to proceed with rotator cuff surgery in 2023. There used to be a time when we did a lot of surgery to remove bone spurs around the shoulder to protect the rotator cuff. That's done much less commonly now, now that we realize that's not as much of a cause of the rotator cuff problems as we thought it was before.

Dr. Dennis Cardone: So rotator cuff surgery has a great track record, very successful. And I think timing is important, but maybe one of the most difficult recoveries of surgeries, I mean just in terms of both pain recovery and time. But just talking about outcomes of rotator cuff surgery.

Dr. Joseph Zuckerman: If you get to the point where rotator cuff repair is being considered, that means you've had symptoms for a significant amount of time, it has not responded to simpler measures of medication, therapy, injections, and is still a source of significant pain and limitation for you. Then you progress to considering having it repaired. Now, almost all rotator cuff repairs now are done arthroscopically. We used to do them with an incision, but arthroscopic techniques have progressed so significantly over the past 15 or 20 years that the vast majority can be done as an arthroscopic procedure. That's a little deceiving, right? Because the arthroscopic procedure consists of multiple small incisions, almost always done as an outpatient. Patients go home the same day they go home in a sling. Everybody thinks it's just simple, straightforward surgery. It's a slam dunk. Well, it's not. Because, first of all, patients are uncomfortable, there's no doubt about it. We have to adequately control their pain carefully and safely. But they will be in the sling for upwards of six weeks. During that time, they may or may not be involved in a therapy program. And it takes a certain amount of time afterwards, four days, five days a week, ten days, to feel more comfortable as the postoperative pain goes away. And during that time, you're relying on the rotator cuff to heal. Now what do I mean by heal? Invariably, the rotator cuff tendon that was detached from the bone has to be reattached to the bone. And that's done through a sophisticated series of steps involving anchors put into the bone and sutures pass through the tendon and then tied in a certain way to hold the tendon there while it heals to the bone. That takes time, six weeks at least, maybe longer. And there is some question whether the tendon actually heals completely, and it probably does with smaller tears. But as the tears get larger, the extent of healing becomes less certain. So six weeks in a sling, then go through an extensive rehabilitation program to regain range of motion. There's no doubt about it that takes time and effort on the part of each patient.

Dr. Dennis Cardone: You know, it really does seem like rotator cuff, and certainly no expert in any way about it, but it certainly seems that rotator cuff surgery is kind of saying, well, why is rotator cuff notorious for nighttime pain and rotator cuff just potentially not to scare patients, of course, but a painful recovery, maybe more so than other muscle tendon surgeries?

Dr. Joseph Zuckerman: Again, I don't have an answer for that, but I will tell you, I do a lot of shoulder replacements, and oftentimes I'll do shoulder replacement of patients that may have had a rotator cuff repair years before, and they'll say to me, is this going to be anything like the rotator cuff surgery? And frankly, it's not. Shoulder replacement is a much easier surgery for patients to recover from than rotator cuff repairs. And that may seem counterintuitive or unexpected, but it's absolutely true. I see it every day.

Dr. Dennis Cardone: What about timing? Because that's important, right? Timing for rotator cuff surgery? Rotator cuff repair - can't wait too long. Maybe don't want to do it too soon. Where do you find that sweet spot?

Dr. Joseph Zuckerman: Well, part of it depends upon the cause of the rotator cuff problems, gradual progression of symptoms, so called overuse and things. Well, you're going to go through a series of different treatments until you get to the point where it's not getting better and you're going to operate on it. That occurs over time. There are some patients who may fall or they may have a partial thickness tear, then they lift something heavy in an awkward way or fall on an outstretched arm that results in an acute extension of the tear or an acute tear. That becomes more significant. That should probably be diagnosed quickly and operated on, repaired early on, because those are usually more significant, extensive injuries different than the meaning weeks.

Dr. Dennis Cardone: When you say early weeks.

Dr. Joseph Zuckerman: Yeah, within a few weeks. Right. That's important because a large tear like that, that may occur from a fall or traumatic injury, that retracts because of the constant contraction of the tendon - the bigger it gets and the more it retracts, the harder it is to repair. So early repair is indicated in those traumatic type injuries as opposed to those that occur gradually over time.

Dr. Dennis Cardone: And maybe not all rotator cuffs. So now, if you talk about the gradual ones, the degenerative ones, there are some that maybe are not that amenable or, you know, findings that you may see on an MRI that say, hey, you know what? This isn't a straightforward pulling that tendon over and tacking it down.

Dr. Joseph Zuckerman: You're absolutely right, because what happens over time is tears get bigger. The bigger the tear, in general, the harder it is to repair. And when you've got a tear that involves more than one tendon, a two tendon tear, two of the tendons involved, or even more than a two tendon tear, that is very difficult to repair. And then again, uh, let me go back to the jean analogy. You may have a hole in your jeans that's a full thickness tear, and it may look small, but if the cloth around it is a very poor quality and you tried to stitch it together just over the open area, it wouldn't hold because the cloth will never hold the thread you're going to put in it. The same thing happens with the rotator cuff. You may have a small or full thickness tear, but the tendon tissue around it may be a very poor quality. It may be very degenerative, worn out, very thin - even if you put stitches in it, sutures, it's not going to hold. So that becomes a much larger tear and a bigger problem to address. Now, there are a lot of different ways we're trying to enhance the rotator cuff repairs using biologics, platelet rich plasma, other similar type material, reinforcing the tear with patches that will encourage healing. All those things may be beneficial, but have not - we've never really identified the holy grail to assure a successful rotator cuff repair in all situations.

Dr. Dennis Cardone: What about the patient that they have that complete tear, their jean has now become cut off shorts. And they say, well, Doctor Zuccoman, I don't care what you say. I don't want surgery on this rotator. I'm not having surgery. Is that an option? How do people do with these complete tears? Do they lose complete function? Are they doomed to chronic pain in that shoulder? Where does that go? Long term, non surgical.

Dr. Joseph Zuckerman: So it is very variable. Some people come in and see me, and they have every find that's consistent with what we call a massive, irreparable rotator cuff tear. It's large enough, involves three tendons, the muscle itself on an MRI is very atrophied. There is no way you can repair this. Some patients will come in and they'll raise their arm up overhead. How much pain do you have? Not much. Have you had to modify things? Well, you know, I only play 18 holes of golf a day, I don't play, you know, 36 like I used to. And they function very well with minimal pain at night. Others with a similar situation may be completely incapacitated. And identifying what differentiates one from the other is very difficult.

Dr. Dennis Cardone: It's extraordinary because there are some patients, like you said, you get the MRI, and the rotator cuff is just completely torn. And they come in the office and they're just about reaching for the ceiling and saying, uh, maybe once in a while I feel it, right? I mean, it really is extraordinary how the body sometimes, I guess, can explain it with just other using accessory muscles. But even then, it's just so different from one patient to the next.

Dr. Joseph Zuckerman: Using accessory muscles are always helpful, but we all have those accessory muscles. I think some of it has to do with how this progresses over time, because if it progresses more slowly, you can accommodate. And some of it just has to do with the degree of inflammation. Inflammation causes pain, and some people's degree of inflammation is greater, right, and they're going to have more pain and be less able to tolerate it. I will say one thing, though, I've never seen a rotator cuff tear or problem that was an emergency. Even the patient who falls and has a very large tear, that may become an urgency to get it repaired. But when I see patients say, well, I saw a doctor and he told me, I have to have this done right away. Well, I would think twice about that. It's not the nature of the problem.

Dr. Dennis Cardone: Doctor Zuckerman, Chairman of, uh, maybe the largest department of orthopedic surgery in the country, been doing shoulder surgery for just a couple of years.

Dr. Joseph Zuckerman: Did you say decades?

Dr. Dennis Cardone: What about when you look into the future, you look into that crystal ball, let's say five years, ten years down the road. Like you said, you've made remarkable advances if you look out over the past 10, 20, 25 years, what do you see coming down the road for rotator cuff surgery?

Dr. Joseph Zuckerman: Well, I guess what I would most predict is the advances in biologics - promoting healing using stimulating materials, whether it be platelet rich plasma, what we call cytokines, to enhance healing is probably there. People ask about stem cells. I don't know where stem cells are going to go. That may be a possibility there. I also think in a parallel way, the techniques we use to repair will also improve. But a lot of that has happened over the last ten years, and we find ourselves still in a position where we've made progress, but not by leaps and bounds. It's by relatively smaller steps. So, I do know one thing, that the use of something like reverse shoulder replacement has been a significant advance for patients with massive, irreparable, painful, disabling rotator cuff repairs. Now they have something that they can be offered a very successful outcome, and they are among the most satisfied and happiest of patients. So that's one thing that has happened. But getting this relatively small amount of tissue, the rotator cuff tendons, to heal, continues to be a challenge.

Dr. Dennis Cardone: I know you've told me with the reverse shoulders patients, uh, they're back on the tennis court, they're back on the golf course. So certainly more to come with reverse shoulders and certainly surgical technique, biologics - fantastic.

Dr. Joseph Zuckerman: So if I had a choice, right, I would prefer not to have a rotator cuff problem, right? As great as we are at it, but if I had one, I know I could be well taken care of and that people could control my symptoms and ultimately resolve the problem in more than 90% of the situations.

Dr. Dennis Cardone: How about one of the final questions on this unbelievably informative podcast? Prevention. So you brought it up. You said, boy, if I didn't have to have it, I wouldn't want a rotator cuff problem. You talked about is a lifetime of wear, and maybe some part of it's just in the genes and the cards. Anything people could do to prevent these rotator cuff problems?

Dr. Joseph Zuckerman: So keep in mind what I said initially, that the shoulder has the greatest range of motion of any joint in the body. When we're involved in physical activity, whether it be occupation related or athletic related, recreational sports, stretching to maintain that range of motion, to maintain that excursion of the tendons, I think will help. There's no doubt about it. Because then you're not asking a tight tendon to do more than it needs to do. That in itself can cause some structural injury. Now, making sure that you avoid excessive use, right, lifting things repetitively when you're not ready to do that, all those things add to the wear and tear on the shoulder. But listen, most of us go through life doing all those things, and we don't really know the impact of it until much later on. But I think maintaining a supple stretching shoulder with good mobility is probably as important as anything else in maintaining the good function of the rotator cuff. Some of this is also genetics, right? Everybody's tendons are not created equal. And that's what I like to refer to as our own individual biology. And that explains why, in part, why some people could have these rotator cuff tears and be asymptomatic, and other people will be incredibly symptomatic and disabled by it. There's not much we can do to control that, since we can't control our gene pool that we choose from.

Dr. Dennis Cardone: Doctor Zuckerman, this has been great. I mean, we've really just touched upon rotator cuff surgery and rotator cuff treatments, really so much more to talk about, and only touched shoulder replacements, which have really become quite an essential part of the armamentarium of treatment for shoulder problems, and a great intervention. So I think we need to get back in the studio and talk more about those things and look forward to the next Bone Whisperer podcast.

Dr. Joseph Zuckerman: I think there's a lot of opportunities to share with our listeners the details of rotator cuff surgery and the advances that you mentioned before, as well as the continuing growth in the field of shoulder replacement. So that's one of the great things about the Bone Whisperer - the more we have these conversations, the more topics we add.

Narrator: The Bone Whisperers is a co production of NYU Langone Health and SiriusXM. The podcast is produced by Scott Uhing, sound design by Sam Doyle. SiriusXM's executive producer is Beth Ameen and senior operations manager is Emily Anton. Narration and additional sound design by Michael Luce. Don't miss a single episode of the Bone Whisperers and subscribe for free wherever you listen to podcasts. To hear more from the world renowned doctors at NYU Langone Health, tune into Doctor radio on SiriusXM Channel 110 or listen anytime on the SiriusXM app. For the Bone Whisperers podcast, I'm Michael Luce. Join us next time for the latest advances in orthopedics on the Bone Whisperers.