»» All right everyone, welcome. So welcome to our session. We'll be doing a point counterpoint on rotator cuff tear management, really focusing more on the gray area cases that we may not encounter. This is pairing nicely with yesterday's session, the game of bones where they focused a little bit on shoulder. But today we'll be really delving into rotator cuff tears more. I have no financial disclosures. Just to introduce our really great panel that we have. So my name is Jen Suhu. I am one of the sports attendings at Cornell and also the sports fellowship director there and I will be moderating today's session. Then we have Dr. Robbie Bowers here, assistant professor at the Department of Ortho and PM&R at Emory University. He's also the director of the Emory Baseball Medicine Program and the head team physician for College Park Skyhawks and the team physician for Atlanta Braves and Georgia Tech Baseball. And then we're also honored to be joined here by Dr. Matthew Best, who's an assistant professor of orthopedic surgery at Johns Hopkins University right down the road here. He's also the director of research in the sports medicine division, the surgical director of orthopedics at Greenspring Station and team physician at Johns Hopkins University Athletics. And then just to give you an outline of what we'll be covering today. So first we'll have a nice 20, 25 minute presentation from Dr. Best, just kind of giving us a nice overview of surgical repair of rotator cuff tears. And then we have a couple cases that are a little bit more kind of gray area on how to manage them. We welcome questions either through the app or if you want to come ask them because we want this to be interactive. And then any time left over will be Q&A. I will now turn it over to Dr. Best. So I have no disclosures related to this talk, although I do receive some support from multiple companies. So I'm briefly going to go over some indications for surgery, patient selection, how we determine who's the best candidate. I'll give an overview of what the actual surgery looks like, the technique and some videos on how we do it. I'll talk a little bit about subacromial decompression and when that is necessary and what the literature says about that. And then I'll get into a little bit of the recovery, postoperative therapy and some of the risks. So when we talk about surgical indications, there are a lot of gray areas in the rotator cuff. One in particular, acute full thickness cuff tears, that's a definitive surgical indication. But those are pretty rare. And when I say acute, I mean a true acute cuff tear. So that's not acute on chronic or exacerbation of a chronic cuff tear. But a true acute cuff tear is a tear of the cuff when there's no atrophy, no prior problems with the rotator cuff. Acute on chronic with good tendon, that can be a surgical indication. But there are a lot of factors that go into that. Chronic tears or partial tears that have not improved with non-operative management. Those are by far the most common tears that we see. And there are surgical indications there, but that goes into shared decision making with the patient. And this talk, I'm not really going over an exhaustive summary of the evidence, but I'm not really the purpose of this talk. But I am going into some of the clinical practice guidelines that we have in the orthopedic society where the evidence has been reviewed at length. And there is very strong evidence to support both physical therapy and surgical repair of rotator cuff tears with notable improvements of functional outcomes and pain over time. And that's really talking about small, medium, and some large rotator cuff tears, but particularly small and medium-sized rotator cuff tears. Chronic and large massive tears are a little bit of a different area that I'll touch on here. There's also strong evidence that rotator cuff size, muscle atrophy, and fatty infiltration do progress over 5 to 10 years in non-operative treatment of rotator cuff tears. And a lot of this is from two very well-done randomized controlled trials in 2014 and 2015 that look at this, both the operative management, the non-operative management. So these are important things that go into the discussion with patients when we talk about surgery. There's also moderate evidence that healed cuff repairs have improved outcomes when compared with physical therapy or patients that have surgery and unhealed cuff repairs. And that sounds like common sense, but in the literature, in orthopedic literature, for a long time patients were thought to do well after surgery regardless if the tendon heals or not. And so there's a lot of debate as to whether or not does the tendon heal or is it a re-tear or is it an unhealed tendon. And it's hard to know that in all the patients because we don't get MRIs in patients post-op and we rarely get ultrasounds in patients post-op, more in the research setting. But those are also factors that go into discussion with patients undergoing surgery. What about injections? There's very good evidence to show that injections can help with pain, as you all know, I'm sure. When we talk about that in the orthopedic literature, it's really more one injection, maybe two injections, but this isn't really a series of injections. When you do too many injections, two, three, four, five, six injections, it can compromise the integrity of the rotator cuff tendon, which may make it more difficult to repair in the future. So I usually tell patients one injection is totally fine. Two injections is okay in many cases. I tell them it's not a good idea to do series of injections unless, of course, they're not surgical candidates or there are other factors that preclude surgery in those patients. Patient selection is very important as well. These are all, all these factors here are variables that affect rotator cuff healing and portend a poor prognosis in patients that undergo rotator cuff repair. And it doesn't mean that we don't do surgery on these patients. It just means that it's good to counsel patients when they have these factors. And these factors can play into the role of whether or not we might recommend surgery earlier versus later, and we can discuss postoperative outcomes with these patients as well. But there's strong evidence that older patients generally do worse, patients over the age of 65. The tendon is usually of poorer quality. A lot of those patients have chronic tears or acute exacerbation of chronic tears. But there's evidence that those patients do worse after rotator cuff repair, particularly with rotator cuff healing or re-tear. There's also moderate evidence that higher BMI patients do worse, and those correlate with higher re-tear rates. Comorbidities and diabetes, those are kind of expected, but there are a lot of patients with these comorbidities, particularly older patients. So these are important to know about as well. This is just a general overview of the surgical technique. And this is just one technique. There are many different ways to do rotator cuff repair. This is probably one of the most common, or this is for sure the most common technique. This is an arthroscopic technique. You can see the cannulas here and the portals. We start by checking the excursion of the rotator cuff, then by preparing the bed, then placing surgical anchors. And some people don't use anchors. Some people do. The outcomes are the same. But this is just one technique here. You can see the anchor being placed where the footprint is. These anchors are preloaded with sutures. These are one company of anchors. There are many companies that make them, and they all work just as well. But the whole principle is to get the rotator cuff tendon down to the footprint of the rotator cuff, the footprint being where you see that burred out area of bone there. Those are the things that correlate most with outcomes after rotator cuff repair. So these sutures are passed through the tendon. You can repeat this with multiple anchors. You'll see another anchor here. So there's two anchors and multiple sutures being passed through the tendon. Now this part is where, this is the concept of double row repair, which I'm sure you've heard of. Double row repair involves anchors on the medial side as well on the lateral side. So it's two rows of anchors. That's what's meant by double row repair. So that's what's being done here. The sutures are being pulled into another anchor, and those are being placed over the lateral side of the tuberosity. That's what's creating the double row. And I'll talk about evidence for or against double row, but it's definitely not needed in all rotator cuff repairs, but it is shown in this demonstration, and it is fairly common in the larger rotator cuff tears. So then this is the end of the animation here. There's finally another anchor being placed in the lateral side, and that's what the rotator cuff repair looks like. Any technique can do this, but the whole purpose is to get this part of the rotator cuff that's torn back down to the footprint. So that's kind of what it looks like at the end with sutures. Two rows of anchors. Again, this is a double row, and the rotator cuff footprint back down to the surface. This is what it looks like in real life. Totally different, of course. Much harder to see, but this is what it looks like from inside. There's clearly the rotator cuff tear there. You can pull on the rotator cuff and check the excursion. There's one anchor being placed into the medial aspect of the footprint. This is what it looks like when you're passing sutures. That's what the cuff looks like. So sometimes it has a bit of a diminutive appearance, but not what it looks like in the books, obviously. More anchors being placed and sutures being passed through the tendon, and again, here's what the lateral row looks like. This is the anchor being put over to the lateral aspect of this cuff tear, and those anchors with the sutures are compressing the torn part of the rotator cuff back down to the greater tuberosity. So that's one method, and again, there are many different ways to do this type of surgery. But this is what it looks like at the end of the case. You see sutures with double row repair, and the cuff is compressed back down to the greater tuberosity. So like I said, there's many ways to do this. There are still people who do open rotator cuff repair, and that works just as well. The studies show the outcomes are the same. It's definitely more common to do an arthroscopic repair now. Probably over 95% of people are doing arthroscopic, but I still know people that do open and the outcomes are the same. And there's many different constructs to use for rotator cuff repair. I personally use anchors. I do a very similar repair as to what was just seen in the video, but there are many different ways to do it. There's bone tunnels that can be made through the bone with sutures being passed through those tunnels, but the principle is the same of compressing the rotator cuff down to the footprint. There's also single and double row repair, which is very important because not everyone needs a double row repair. In fact, most people don't, and double row repair is significantly more expensive than single row repair, and anchors are more expensive than bone tunnels. So these are all important factors that go into decision making when repairing a rotator cuff. But there's been very many transitions that have occurred through this process of rotator cuff repair evolution. So when you look at rotator cuff repair, again, this is a study that looks at factors in outcomes in rotator cuff repair, and there are many different things that people look at. There's suture type, number of sutures, number of limbs, how you pass the sutures, anchors of course, and bone tunnels. And this meta-analysis looked at all these factors, and really what it showed is the most important things in the rotator cuff repair was number of sutures and suture type, meaning if you can get a good area of compression over the rotator cuff repair and you have thicker sutures, they can push the rotator cuff repair down. And it showed that anchors weren't necessarily better than the other methods of doing it. It's really just the technique, the way you put it down. So this is important when we talk about costs, since the way I do it and the way some other people do it unfortunately costs more, and we'll see how much longer we're allowed to do that. But there's strong evidence to support that double row constructs are not needed in the routine case of a rotator cuff repair. Now there is other evidence that shows in some larger tears, there are lower re-tear rates with double row repair, and this is a schematic of what single and double row looks like. So double row is not used routinely, it has to be used in selective cases. I try to get the rotator cuff back down to the footprint with a single row. If needed, I'll do a double row, but it's not routine. And you can clearly see here it's twice as many anchors, which really ends up being twice the cost in some cases. This is a breakdown of how much the anchors cost. Now this is what they are currently. I think in the future we'll get lower and lower costs out of these anchors. But you can clearly see the more anchors you use, the higher the price. And there's those two bars on the bottom are methods for transosseous repair, or placing the sutures through the bone itself, much cheaper at a fixed cost compared to the anchors. Now what about subacromial decompression? This was a surgery that was extremely common for a long time. And what that means is removing some bone spurs from underneath the acromion, or shaving smoothing down the surface of the undersurface of the acromion. And obviously right below that is the bursa and the rotator cuff. So the thought for a very long time was pathology underneath the acromion was a cause of rotator cuff disease, because it is intuitive that if you have spurs underneath the rotator cuff, if the rotator cuff is impinging against that, it can cause tears in the rotator cuff. And that was dogma in the orthopedic literature for a very long time. And then we realized that that's not the case, that the undersurface pathology of the acromion is actually an effect of rotator cuff disease, a progression of rotator cuff disease. So when we realized that, our behavior with the literature correlated, and we stopped doing isolated subacromial decompression. So subacromial decompression was performed in an isolated case for many years. And we realized that was no better than physical therapy through many, many studies. And that became a very rare case. Now subacromial decompression is not performed in isolation. It's still performed in some cases of rotator cuff repair, more for visualization and other reasons. And we'll get into that also. But this came out, and everybody's probably seen this. If you type in unnecessary shoulder arthroscopy, this is the first thing that comes up, is a common shoulder surgery useless. So that's pretty embarrassing for a shoulder surgeon. And there's over 500,000 hits for this on Google. And what this is referring to is subacromial decompression, particularly when performed in isolation. And again, this correlates with our various studies. This was one that looked at isolated subacromial decompression versus placebo surgery. So surgery without subacromial decompression, no benefit at two years, same thing, no benefit at five years. There have been many other studies that looked at this and compared it with physical therapy and no benefit for subacromial decompression. This study looked at trends of subacromial decompression when performed in isolation and when performed with rotator cuff repair. And as expected, it somewhat correlated with our knowledge of the literature in the top of that graph there is subacromial decompression when performed in isolation, which you see a pretty drastic decrease. You probably should see more of a decrease there. And the bottom part of the graph is subacromial decompression when performed with rotator cuff repair, and probably should see a little bit more of a decrease there as well, because it's not to be performed in routine cases of rotator cuff repair, only in certain instances. And this was a pretty important commentary that talked about that. And it discusses how our behavior not only correlates with evidence, obviously, but with reimbursement. And as the evidence comes out, reimbursement decreases, and then obviously that can decrease what surgeons are doing as well. And it's not in a negative way, but we're just following the literature. This is important also for bundled payments, because bundled payments have not really hit rotator cuff repair yet. So the more CPT codes you do or the more procedures you do at the time of rotator cuff repair, will increase the overall cost of that case or the reimbursement of that case from the insurance company. So we've seen bundled payments in total knee replacement and total hip replacement, obviously, but that has not come to rotator cuff repair yet. So we may see more changes in those trends once bundled payments hits rotator cuff repair. And you may see that also with anchors in double row repair and other factors that increase costs. So there's moderate evidence against routine use of acromioplasty. That's what a true subacromial decompression involves, acromioplasty, which is shaving underneath the acromion. So when do you do it? There's still, why do we see the bottom of that graph in subacromial decompression trends? It's because people are still doing it when performed with rotator cuff repair, and definitely over half of surgeons are doing it in the cases of rotator cuff repair, more so in patients with significant pathology underneath the acromion. The literature is somewhat limited in the area for long-term outcomes. Certainly in short-term outcomes, there's no benefit to it whatsoever. But in long-term outcomes, we don't really have that data yet. It's very safe, quick, and it's low cost to perform a subacromial decompression. It takes about five minutes to do. It doesn't increase the direct cost of the case, as there's no implants. The benefit to it down here in bold is probably why most people do it, and this is the reason I do it in certain cases of rotator cuff repair, is to aid in visualization. So you remember the schematic with all of the cannulas and the portals? It can make it a little bit easier to see and perform your rotator cuff repair without pathology right above the rotator cuff. Patches, augments, and biologics. This is a huge area of research, obviously, and it's hard to discuss it in a brief lecture, but there's strong evidence against the use of these when used concomitantly with rotator cuff repair. Obviously, we use them in cases without rotator cuff repair when comparing them with injections and non-operative treatment, for example. But in the case of rotator cuff repair, there's no evidence to support their use right now as adjuvants, and that's particularly for biologics and augmenting patches and things like that. In the future, there may be some benefit to it, but right now, the evidence is against that. Now, what about recovery? There's been a lot of debate on recovery after rotator cuff repair, how quickly to get patients moving, what stages they go through. Pretty much everybody starts with immobilization. That's the first stage. Now, that doesn't mean no movement at all. It means they're in a sling for the first six weeks to help the rotator cuff heal. Now, there's been a lot of studies looking at, when do you start passive range of motion? And there's good evidence to show there's no difference in whether you start passive motion at two weeks or if you start passive motion at six to eight weeks. So starting at six to eight weeks would be an immobilized patient, no mobility for the first six to eight weeks. But there's really no difference between the two. So most people will start getting patients to move in the first two weeks to four weeks. Some people let them do gentle passive motion immediately. But this is important to remember. This is patients that are still wearing a sling for six weeks. They're not walking around and moving whenever they want. And again, this has showed multiple studies, a difference between early and delayed mobilization up to eight weeks. And again, that's with a sling on. After that, we typically will do more passive exercises and then progress to active exercises after anywhere from six to eight weeks. Strengthening doesn't really start until at least 12 weeks or so, 12 weeks to 16 weeks, depending on how they do with physical therapy. And the entire recovery is six months, sometimes nine months, depending on the size of the tear and depending on what patients are getting back to. So these are important for counseling patients. And when you talk with patients about how quickly they can get back to activities with non-operative treatment versus operative treatment, I tell patients the operative treatment is pretty long. It's longer than you might think. It's usually six weeks in a sling. Then it's physical therapy that's very gentle for several months. And then they progress their strengthening. But I tell them it's at least six months and can be out to nine months. So that's a very significant length of time, particularly for people getting back to work that are doing manual labor or things like that. So a very important part of the counseling for patients. Complications are pretty low after arthroscopic rotator cuff repair. Nerve injury is very rare. And this is axillary nerve injury in particular. Infection, less than 1%. Deltoid detachment, this is really a problem with open rotator cuff repairs. People that perform these in an open technique have to take down a little part of the deltoid in order to perform this repair. So it's pretty much unheard of in the arthroscopic technique. Stiffness and tendon re-tear are probably the biggest problem. Stiffness is a big issue. And I tell every patient, you're going to get very stiff. But usually by three months to six months, a lot of that stiffness will improve. And then we talked about early mobilization versus delayed mobilization. There may be some benefit to early mobilization in the first six months. At one year, there's no difference at all. So I tell patients, they're going to be stiff. And eventually, that's going to get better as long as they're doing the physical therapy. Tendon re-tear is a very debatable concept in rotator cuff repair because it sometimes can be hard to differentiate tendon re-tear versus a tendon that just didn't heal. And we talked in the beginning about factors that are associated with non-healing of rotator cuff tears. And again, older age, obviously, is one of them. Comorbidities and things like that. But larger tears is probably the highest risk. So when we talk about rotator cuff tears and terminology of rotator cuff tears, it's kind of unfortunate because the terminology is so poorly used. Full thickness versus full width versus massive versus small, medium, large. In general, a massive tear, there's many definitions to it. But it's two or more tendons with retraction. Now, there's other factors that go into that, how exposed the greater tuberosity is. But there's a lot of debate as to these things. But larger tears definitely have a higher risk. Older patients have a higher risk. And we talked about how due to age and poor quality of their tendon. Now, what about re-tearing after rotator cuff repair? For a long time, it was thought, whether it heals or not, they're going to get pain relief. And they're going to get improvement in function. It's not always the case that a re-tear leads to more pain and decreased function. But now, with more studies, we do know the function is definitely worse in patients that have retorn tendons, whether or not they have pain relief. Revision is only needed in cases that they have really significant symptoms despite more physical therapy. So just the fact that there is a re-tear or lack of healing clearly not a surgical indication. So overall, just to summarize, indications of acute full thickness tears are a clear surgical indication. They do better. They have lower rates of fatty atrophy at 5 to 10 years. They have improved outcomes. But it's important to differentiate that from an acute on chronic or a chronic with exacerbation. I get patients every week that come into clinic with a reported acute rotator cuff tear. They may be 60, 65 years old. And I look at the MRI, and there's diffuse fatty atrophy everywhere. That's clearly not an acute rotator cuff tear. That's an acute exacerbation of a chronic rotator cuff tear. So a true acute full thickness rotator cuff tear is pretty rare. That is less than 10% of what I see anyway. And that is a definite surgical indication. Acute on chronic, you have to look at the degree of tendinosis, the degree of fatty infiltration of the rotator cuff muscles. And you have to look at the big picture. But many times, those can be surgical indications. But there's a lot that go into that decision making. Chronic with persistent symptoms, these are the most common patients. And those are patients that have to fail pretty extensive physical therapy in order to be considered for surgery. Constructs, there really is no construct that is better than the others. Double row may have decreased re-tear rates in some of the medium and larger size tears. It's certainly more expensive. It's not needed for every surgery. The important thing is getting the rotator cuff back down to the footprint with low tension and good compression. Subacromal decompression, there's no evidence to do this in isolation. There is poor evidence to do this in the setting of rotator cuff repair. Now, in certain rotator cuff repairs, it may be beneficial, particularly for visualization and making the procedure easier. As far as pain and outcomes, there's no benefit to doing this in rotator cuff repairs in the short term. Long term, we really need better studies to look at that. That's it. I'm not sure where I am on time. This didn't have the time on it. Thank you very much. Thank you very much for that, Dr. Buss. That was very helpful. All right, just wanted to pause if anyone had any really quick questions before we moved on to the cases. All right, so we'll jump into our cases now. So Dr. Buss went over who are the very clear surgical indications. But as we've all encountered, we've had people where we're not sure whether we should send them for surgery or if they have an athletic event or something coming up pretty soon. Like, do we make that decision sooner? So hopefully, we will hear some expertise from our panel here. So our first case here, so we have a 45-year-old healthy male who fell climbing a fence six weeks who acutely injured his right shoulder. No, it's OK. He has no prior history of shoulder pain or injury. His main form of exercise is golf and running. He's a nonsmoker, normal BMI, has two kids at home, would like to be able to play catch with them. Physical exam shows pain and weakness with full can-empty-can tests, not really able to actively abduct a shoulder due to pain, has full passive range of motion. You get an MRI that shows an acute high-grade partial articular-sided supraspinatus tear, which is greater than 75% width of the tendon with underlying moderate tendinosis, has some mild tendinosis of the infraspinatus and biceps tendon, no fatty atrophy of the muscle. He says he's going on a once-in-a-lifetime golf trip in four months. He doesn't want to, this is very common in New York, by the way, he doesn't want to wait and do PT first if he will need surgery, and he would like the intervention with the highest likelihood that he can go on his golf trip without any pain or loss of strength that might affect his game. What would you advise? And I will go to you first, Dr. Bowers. Let me know if you want me to click. I apologize to everyone. I woke up in the middle of the night significantly under the weather, so sorry if you can't hear me through the mask. I apologize. And most of my thoughts are going to come from the rotator cuff review paper that we wrote earlier this year. This is it. And so anything that I mention when it comes to data should be in this paper as far as looking to find that literature to support the comments that I'm making. This is a treatment algorithm that we put together in that paper. And it may have, you may find some things in it that are a little bit different than what you may see in traditional practice. But as you come through the literature, you find that some of these things are very much indicated from a data standpoint. So with that said, this is a gray area one. So this is where I am interested in Dr. Best's take. So a 45-year-old guy with a large partial acute rotator cuff tear, part of me would go directly and send for surgical referral right off the bat, but I think in real life, I may go that route in this person. I think that the kicker is him wanting to go on this golf trip in four months. And Dr. Best talked about the recovery, and he's not going to be going on that golf trip in four months if he has surgery. There's some data in the literature that for some of these high-grade partial rotator cuff tears, that after six months of physical therapy, some of those patients actually do better with surgery after doing some quote, unquote, prehab. And so that may be something that I go after in this patient is physical therapy to see if we can't get his function to the point where he's happy to where he can go on his golf trip. And then we'd also talk about different injections to help him from a pain relief standpoint if he does have significant pain. Now, in an acute rotator cuff tear, and we go through this in our paper, I'm not going to inject corticosteroid around an acute rotator cuff tear for fear of further degrading the tendon. And then if he does have surgery within six months of having a corticosteroid injection, that can impact healing as well as infection rate. So I'm not going to do any sort of corticosteroid injection in this patient. If we do discuss injections, the two things that I will discuss with them is, one, a suprascapular nerve block, which does have compelling data in the literature to support its use in these cases. So that, you're not even close to the rotator cuff. And so you can do a suprascapular nerve block. And then secondly, I'm a huge proponent of Catorlac. And so if you look in the literature as well, Catorlac is non-inferior to corticosteroid and subacromial injections. We don't have the data from a partial rotator cuff tear standpoint, but there are several randomized controlled trials comparing it to corticosteroid for subacromial impingement. And there's actually one trial that shows that Catorlac does better. So from an infection and toxicity to the tendon standpoint, Catorlac seems to be a better option. And so those would be the two injections that I would discuss with the patient, as well as physical therapy, and try to come up with a plan as far as his goals with going on this golf trip. Now, if you take the golf trip out of it, then I may send him to have the surgical discussion first, and happy to see him back afterwards to go through some non-surgical treatment after you kind of get the blessing on the surgical side. Thank you. Dr. Best? Yeah, I agree with that. I thought maybe I wouldn't be the best person to debate these cases, because I agree with non-op for them. But for this patient, yeah, I would send him to physical therapy for sure. I would actually look at the MRI. I look at all the MRIs myself, because there's a lot of terminology that's maybe not very clear cut on MRIs, depending on who reads it. But when we talk about full thickness and partial thickness, we're talking about the depth of the tear, so from top to bottom. And that can be small, low grade, less than 3 millimeters. Half of the depth is roughly 5 or 6 millimeters. And a high grade is more than 6 millimeters. But when you talk about the tears from a width standpoint, they can be very wide or very small. So even a full thickness tear can be a pinpoint tear of the very front of the rotator cuff that's maybe only a millimeter or two in width. That's completely different than a tear of the entire supraspinatus tendon or two tendons that's full thickness. So it's very, very different based on what the read says on the MRI. So I look at the MRI myself. I look at actually how wide it is, how deep it is. But for a partial tear, I would start with physical therapy and then see how he does over the course of six to eight weeks. His expectations are not realistic, which is often the case. But certainly, if he has a golf trip in four months, I actually get these kind of patients, too. This sounds like one of mine. But I tell patients, if you have something coming up, some type of event, the rotator cuff repair is six months to nine months of a recovery. Now, the question is, is it a repair or is it a debridement? With partial tears, you can do a repair of the rotator cuff, meaning complete the partial tear and repair it. Or you can do a debridement. Or you can do an in situ repair. But most patients, I think this person has some tendinosis on his MRI, correct? Some moderate tendinosis. Yes, moderate tendinosis. It really depends on the quality of the tissue. Most of the time, the patients that I see anyway, especially patients who are a little bit older with some tendinosis, the surrounding tendon around the partial tear is often a little diminutive or some poor quality tissue. And it's better just to take that down and do a rotator cuff repair. So that's a six to nine month recovery, probably six months or seven months for this patient, whereas a debridement may only be four months. So perhaps if he had a debridement, he would get back in time for his golf trip. But this is a higher grade partial tear, so that's probably not going to be the case. But I look at the MRI on every patient. I think that's probably one of the most important parts of working up rotator cuff patients is looking at the MRI, because there's such wide variability in rotator cuff disease. But I agree with what you said also. Yeah, and I would echo that. I've been burned a couple of times with going off a radiology read when you're in a hurry and sending them, and you get feedback that, eh, it's really not that big, and they send you back for non-operative treatment. So it's just a pearl to look at the imaging yourself. So would, Dr. Best, would your decision change if his golf trip was like eight months away instead, and it was a pretty decent sized tear? No, I've never operated acutely on a partial rotator cuff tear. I know some people do, but I think that there's a lot of debate about that. I still would send the patient for physical therapy. If it were eight months away, and I would send him for maybe four weeks of physical therapy or maybe a shorter course, and if he's still having a lot of pain and getting worse, then I would do the surgery, and then he would still maybe be back in time. But I would still send him for at least some physical therapy. If it were a full thickness tear, that would be totally different. Or an acute on chronic, that would also be a little different. But in this case, I would still do that. That's helpful. Dr. Bowers, we're getting a lot of questions in the chat here about the suprascapular nerve block that you mentioned. Why do the suprascapular nerve block, and what medication do you usually put in it? What was the first part of that question? Why do you do the suprascapular nerve block? So for pain relief. So there are pain fibers that supply some of the cuff, and the bursa. They're the subacromial subdeltoid bursa. And so by doing the suprascapular nerve block, you can block those pain signals. From a medication standpoint, we will use a short-acting local and a long-acting local. Generally, what we use is a combination of lidocaine and ropivacaine, and may use a quarter to a half cc of steroid, just in case there is any secondary irritation of the nerve. And so that is the medication we generally use. We'll use between two and three cc's of each of the locals as well. So not a really large volume, and certainly always use ultrasound guidance to identify the notch and then do that injection. But something that I use fairly frequently in rotator cuff tears, if there's any sort of gray area as far as whether they're going to proceed to surgery. It's something where you're staying away from the structures that will be operated on, and can also provide significant pain relief, as evidenced in the literature. Great, thank you. And then I have a comment in here. Someone wants either of you to comment on viscose supplementation, Hilonex, or vitreous injection. Yeah, so I think that that is, and that's in our paper as well, I think that's an area that fewer people are familiar with. There actually is, there are some smaller trials that show that subacromial injections of hyaluronic acid can be helpful for partial rotator cuff tears. But we go over that in the paper. Certainly insurance isn't going to cover it. At Emory, we have an option where a patient can pay $250 out of pocket and for a series of three hyaluronic acid injections. And that's fairly palatable to some, but it's certainly an option that is going to be healthier for the tendon. And we think that hyaluronic acid has some pain relieving and anti-inflammatory properties as well. So, it's certainly an option. It is kind of the next step of what I'll discuss. And so, first, I generally will discuss suprascapular nerve blocks, subacromial, catoralac injection. And then, if they don't get the relief they're looking for with that, then when we go to the next step and talk about some of the options that are not covered by insurance, if we get to that discussion, that's where I will discuss hyaluronic acid in that situation. Great. Thank you. Then, we have a question about, you know, when, what is your decision on when or when not to do an MRI, especially if someone's coming in with, like, a traumatic injury but are able to abduct their shoulder greater than 90 degrees? Would you still get an MRI or what is the decision tree that goes through? I think there, you know, there's a lot of debate there. If the patient has a traumatic injury and there's significant weakness, then I get an MRI, especially if they're over 40, given the incidence of acute rotator cuff there and the fact that you can benefit them if you catch a, you know, if you find an acute rotator cuff tear there. So, I use it more when there's something that can be done from the findings of the MRI. So, patients, so even if they can still abduct their arm, if they, not a lot of patients come in with true pseudoparalysis where they can't lift their arm, but they certainly do. But a lot of patients just come in with significant weakness after a fall or some type of traumatic event. And in those patients who are older, if there's significant weakness, I would get an MRI. Also, in the young athletic population, there's a little bit lower threshold for getting an MRI there, too. And as you know, in the professional population, there's pretty much no threshold. If there's any pain whatsoever, an MRI can be obtained pretty much immediately, unfortunately. But, you know, it's kind of a different scenario. Yeah, my fear with some of these is holding on to some of them too long before I send them for consult. And so, if there's any acute aspect to it, whether we think it's acute on chronic or acute, then I'll generally have a low threshold to order an MRI just for peace of mind and to make sure that we're not recommending something that may not be the best for the patient. Great. And then I have a question here. How much Catorlac for the injection, and do you use lidocaine with it? Yeah, so Catorlac, in the literature, when you look at several of the studies actually use 60 milligrams, which is a fairly high dose of Catorlac. I'll go between 30 and 60, no real, you know, science behind that. But if you go by the literature, they use 60, but I've used 30 as well just to use a lower dose of medication. And then I do not use lidocaine in with the injection. We use ropivacaine just from a toxicity standpoint. So I'll actually use Catorlac and saline and some ropivacaine just because ropivacaine has much less toxicity of soft tissues than lidocaine does. For a case like this, and I know you said there's not much literature on tears, are you still putting it in the bursa or are you putting it in the tendon? In the bursa generally is what we'll defer to and we won't put it directly into the tendon. And then a question, if a patient is being considered surgery, could you still use Catorlac to help decrease the pain, understanding that with steroid, there is at least a three-month wait after injection before surgery? Yeah, I'll be interested in Dr. Best's thoughts on this. So I do in those situations, sometimes I'll hit them with both a suprascapular interblock and a subacromial Catorlac injection just because in reviewing the literature, there does not seem to be any data as far as increased infection rates or decreased healing after rotator cuff repair after that where we see that with corticosteroids. So at this point, I will do that if I think that they're, you know, likely headed to surgery. Yeah, from a surgical standpoint, the thing we're really worried about is cortisone. And it's for two reasons. One is multiple cortisone injections, like I mentioned, can cause issues with the tendon. That's more over a longer period. But short-term, there's increased infection risk when you do it too close to the time of surgery. And that's particularly borne out in the arthroplasty literature. So I tell patients who are getting a shoulder arthroplasty and a lot of them have had injections that I don't want to do it, definitely not within three months. And sometimes I even push it a little bit more, but certainly not within three months. It's a little less of an issue in soft tissue cases like this. But there are implants that go in, like I showed, a lot of people do use implants. And the infection risk is a little bit higher. So there's actually two reasons that I wouldn't want somebody to have a cortisone injection if they were, you know, planning on getting surgery in the short-term or, you know, we're leaning towards that. How long do you require them to wait if they have had one? About three months. Three months. It is three months. Okay. Have you ever had anyone have a patoral act injection before surgery? I've had, I don't think before surgery, no. I've seen patients that have had them, but I've not had anybody with surgery. I wouldn't mind, you know, it wouldn't affect my surgical planning. Okay. That's good to know. Another question here, what is the role of diagnostic numbing to determine amount of pain-limited weakness, would this change your decision to order MRI or start with PT first? Yeah, that's the kind of, I touched on that a little bit with pseudo paralysis. This patient, they can't abduct the shoulder at all. Yeah, so I mean, you could do that. That's definitely kind of the textbook answer is to use some local anesthetic to see if they can lift their arm up, but we already have an MRI on this patient anyway. So, but yes, that is kind of an answer for somebody that can't lift their arm in that sense is correct. So would you do that, like for example, you didn't have the MRI, they came in, you would do that to make the decision whether to get an MRI or not? I'd still get an MRI, but yeah, that is kind of the, you know, cost-saving measure that you could do that. But in real life, I'd still get an MRI on them. Yeah, in real life, I don't think I would do it. In that situation, to see if it is truly just pain-limited, but we use diagnostic injections just to determine if there are any other pain generators. So not necessarily this case, but if someone's older and you see on imaging, they have a little bit of glenohumeral arthritis, is there, you know, is there an impact from there? So we use diagnostic injections there to see if it is truly just the cuff or whether there's other pain generators. Yeah, I would follow up on that, that that's, I didn't really talk about that at all in my talk, but it's really important to determine where the pain is coming from, because there's really, different than the knee, there's so many area, well, the knee does too, but in particular in the shoulder, there's so many areas that can be painful. The distal clavicle, AC joint, the bursa, obviously the rotator cuff, the proximal biceps tendon, posterior pain from suprascapular nerve compression, from posterior labral tears, from spinal glenoid cysts and things of this nature. So there's a lot of different things in the shoulder. Obviously, you all know this, but I really look on my exam where the pain is coming from, because I see a lot of patients that come in with rotator cuff pathology and all of their pain is isolated to their proximal biceps tendon. So it's very important to tease out where it's coming from, and sometimes in patients where I'm not entirely sure where the biggest issue is, I'll send them for, you know, to the RPM and our team who will do an injection and kind of somewhat diagnostic in that sense, an ultrasound-guided injection. Awesome. I think we have a question from the floor. Yeah. Dr. Bowers, so just in your anecdotal experience, so this trip is four months away. What's the duration of pain relief for both the suprascapular nerve block and the contortillac injections? And then secondly, how many injections do you typically do before you get a surgical consult? Those are good questions. So generally, if you look in the literature, and this is with corticosteroid injections, too, you look across the board, generally, it's short-term pain improvement. So generally, the way that I'll counsel patients is that we're going to do these injections to get you some pain relief on the front end so we can get you into therapy and start to work on your function, and that'll kind of give you the long-term improvements we're looking for. So that generally is what we'll mention, and, you know, we know from the literature that patients do really well with those type of injections, six weeks, and then it's kind of a gray area between six weeks and 12 weeks. So generally, we'll say within, you know, kind of a three-month duration, generally. Certainly, there's some patients that do great with them and come back a year later and say that helped me for a year, but generally, I'll counsel patients that we are, you know, we're looking for short-term pain relief that we can then work on in physical therapy to work on their function. Thank you. I think we have another question over here. Yes. As far as the golf trip, are you going to put any restrictions as far as the amount of time or force they can use with the swing, given that there's underlying tendinosis or, like, risk of progression to a further tear? Do you see that? Yeah, I missed the last part. Given that the risk of progression in the setting of, like, underlying tendinosis. Yeah, I guess it depends on his golf swing. I mean, my golf swing is really bad, and if I swing too hard, it hurts multiple areas. So this, yeah, I would, it kind of depends on his symptoms at the time of the trip. At the time of the trip, how much he's progressed with physical therapy and how his shoulder feels. I tell patients, in general, when you have any rotator cuff pathology, any overhead lifting or overhead activity or lifting away from the body, any heavy or repetitive movements in those areas can certainly exacerbate any rotator cuff pathology. So I tell them to kind of try to avoid some of those things. As far as risk of progression, we don't really know exactly what causes progression or who progresses or at what rate. We know from multiple randomized controlled trials that five to ten years after non-operative treatment of rotator cuff disease, there is a much higher incidence of tear progression in size and atrophy compared to operative treatment. But we really need more studies on what causes it and how to detect it and who, you know, who we see it in, so we don't really know as much about that. So it's hard to say, you know, what type of restrictions I would place on him. It's kind of more his symptoms at the time of it. Yeah, I would, I generally will ask patients to kind of let pain be your guide so he can, you know, grip it and rip it and doesn't have much pain, then I'll let him do that. And a lot of it depends on how he's progressing in therapy, too. But generally, I'll tell him, let pain be your guide. If it's painful during your golf swing, then it's probably your body telling you you need to peel back a little bit. Josh, I realize I didn't answer the second part of your question. As far as how many injections that I'll do, I think that changes from person to person how long it's helped him for, how are they progressing in physical therapy. So I think that that will change from person to person. I won't have a set number to say, okay, this is it. This is how many that you're getting. And then I have a question. So I know you guys talked about that you really wouldn't like to do cortisone injection in this patient, but if, I guess, if you were to do a cortisone injection into the bursar, how long would you recommend them to wait to begin PT with strength training? I'm okay generally with injections. I'm okay with people beginning as soon as possible. So if we did an injection and they started PT the next day, I'd be perfectly fine with that. Because, you know, if we can get them pain relief and get them into therapy sooner rather than later, that's, you know, less painful physical therapy as a probe for us. Yeah, I agree with that too. I mean, I think most patients, just to follow up on that, most patients I think a cortisone injection would be fine here. But if somebody is kind of, has a time crunch or they're leaning towards surgery or they're already thinking they might go to surgery, that's the only time you might want to reconsider it. But in a normal case like this, I think a cortisone injection would be a good option. Yeah, and I think cortisone in this situation, if we didn't think that they were going to progress to surgery or if they had a contraindication to NSAIDs, then we certainly could do a corticosteroid injection if we wanted to. And we can, you know, you can get into the toxicity of the different corticosteroid injections and we can go down that path. But I think it's certainly reasonable based on individual patients. I will say that there is one trial looking directly at suprascapular nerve block and subacromial corticosteroid injections in a subset of patients with partial rotator cuff tears and the suprascapular nerve block group did better. So we do have that data that's out there as well. So I have transitioned to doing fewer and fewer subacromial corticosteroid injections. Any work restrictions? I guess we don't really know what he does for work, but any specific restrictions if he does not, you know, get surgery, especially if this is his dominant arm, that he has this tear, if he's presenting kind of right away after this? And for how long would you restrict him? Yeah, I would treat it kind of the same way as what we talked about with the golf. It depends on what his job is and depends on his symptoms. Obviously, now, at this point, he couldn't do any overhead lifting or, but it really depends on the job. Desk work, he wouldn't really have restrictions, obviously. If he's doing manual labor, he certainly can't go back to work like this. So, and it could be, you know, three weeks. It could be more, depending on how he progresses with physical therapy. But it also depends if it's workers' comp. I have a similar patient who's workers' comp and he's been out for probably 10 months, which is obviously not normal. But, you know, I'd say probably three to six weeks is probably realistic. And then we have a lot of people who have little ones at home who may encounter this. What about, how much can they, do you restrict them picking up their kids or playing with their kids, you know, that type of thing? I wouldn't, I wouldn't restrict them on that. I just tell them try to hold the child closer to your body instead of away or, you know, I hope nobody's doing it overhead. But certainly if they're down here by their bodies, it's much less stress on the shoulder and more on their biceps and forearms. So that's how I would counsel them. So no airplanes. No, none of that. And then before we move on here, just last couple questions. Does it matter which steroid or dose? So if you look in the literature from a toxicity standpoint, dexamethasone, which is non-particulate steroid, has the least toxicity to soft tissues. And so I almost exclusively use dexamethasone in my clinic. And I also think if you look in the literature, not specifically for this pathology, but if you look in the literature, higher doses of steroid versus lower doses, the higher doses of steroid do not outperform from a functional standpoint or a pain relief standpoint. So I actually use, generally my go-to is a half cc of corticosteroid. And so I'll use a half cc of dexamethasone in all my injections. And I haven't studied it, but anecdotally haven't noticed any changes in outcome. So that's generally what I use. Do you use any specific? I use either dexamethasone or whatever our clinic is cost-saving to me. But I use pretty similar. I use either a half cc or one cc, and then I might put four cc's of local in with that. Awesome. And then does this impact the conversation regarding swing and load management? Like if you wanted to keep practicing for this golf trip? I know it depends a lot on kind of his pain and tolerance of that. But kind of like people are very specific and be like, okay, like please tell me exactly when can I do what? Yeah. So what's great with golf is we have these Titleist certified golf PTs. And we have several of them around Atlanta. So generally if I have a golfer like this and they have a lot of questions about swing progression and those sorts of things, then I'll get them set up with one of those PTs and it generally helps me out. And they can guide a lot of that. Great. Thank you. So I just wanted to move on to our second case. So we have some time here. All right. So case number two. So we have a 65-year-old active female tennis player who presents with right shoulder pain, which is her dominant arm. History, no prior shoulder injuries, but kind of had been noting some slight discomfort in her right shoulder over the past six months. But nothing that has prevented her from playing tennis. Then eight weeks ago, she noted significant pain and weakness in her right shoulder after an overhead serve. And before she came in to see you, she's been resting in over the eight weeks. She had a friend who was a PT who gave her some exercises, which she's been doing, with some mild improvement in pain. She's able to do most of the things around the house with only mild discomfort. But every time she tries to go back to tennis, she's been unable to return without significant pain and a lot of noticing a lot of weakness with her serve. Physical exam, she was almost full, you know, range of motion and she's having a lot of pain and significant weakness with all rotator cuff testing. MRI, because you already have this MRI, shows a subacute full-width tear of the infraspinatus and infraspinatus tendon on underlying moderate to severe tendinosis. Some mild retraction of the fiber, some mild fatty atrophy of the supraspinatus and infraspinatus muscle has moderate tendinopathy and partial tearing of some of the tendons around it. Some mild joint arthritis, also very common person in New York. She really wants to get back to playing tennis. This is a huge part of her quality of life. And she wants to get back playing as soon as possible. What would you advise? So this is kind of a classic picture of somebody that comes in with what's thought to be an acute rotator cuff tear and really it's not a true acute rotator cuff tear. So there's a couple things that are important here. One is, again, I look over the MRI very closely to actually see how much atrophy there is. But my guess is it's been definitely probably more than six months, even though that's what she said. She noticed some mild discomfort. But this has been going on for longer than that. It's somebody that wants to, you know, if they want to get back to tennis as soon as possible, certainly surgery is not the answer here, but nonetheless I would still send her for some organized home exercises or some in-person physical therapy first, and then this is somebody that I would anticipate would probably, you know, come back and progress to surgery. But I would still give her the option to, I would still have her start physical therapy and see how she does with that. But it's a pretty classic example. This is probably one of the more common things that I see, patients that get referred to me for an acute rotator cuff tear, and it's not truly an acute rotator cuff tear. And there are a lot of clues there, just the fact that somebody's 65 is one clue there. By the time somebody gets to be 60 to 70, there's over 60 percent incidence of rotator cuff disease, even in asymptomatic shoulders. So the fact that they're 65, it's pretty uncommon to have a true acute rotator cuff tear with no underlying tendinosis or atrophy in somebody who's 65. Then obviously the MRI confirms that. So I would send her to formal in-person physical therapy or a structured home program for at least six weeks. This is somebody that I would offer a cortisone injection as well. There's no real timeline or not really worried about that, so I would offer her that as well. As the literature would say, one, there's moderate evidence for that. Doing more than one is not the best option, but I have some patients I would offer them two as well, but I wouldn't do a series of three or four injections in her. But then I would see her back pretty quickly, six to eight weeks, and see how she progresses with the physical therapy. Before we go on, in this type of scenario, as you see it really commonly, how likely are these people progressing to surgery anyways, and how do they tend to do afterwards? A lot of them actually come back and they feel good. A lot of people don't want surgery when they know how long the recovery is, and surprisingly, I do see a lot of these patients come back without much pain, and I counsel them. One of the important long-term effects of non-operative treatment of a full-thickness rotator cuff tear is that it does progress. We know that it progresses. It kind of depends on how much arthritis she has, if she has any superior migration of the humeral head at this point. But I tell them it is going to get worse. It's not going to heal itself, and by five to ten years, you will have worse atrophy, you will have more fatty infiltration, and you will have a larger tear, which may or may not preclude a rotator cuff repair at that time. Certainly if it's significant atrophy and a significant retraction, it may be irreparable. So I do counsel them in that area, but I do have patients that come back without much pain or with almost no pain, and it's hard to tell, it's kind of difficult to tell somebody you have to undergo surgery if they're 65, they're back to functioning normally, and they have no pain. I think it's a hard thing to do that. Now if they're 40 and they have a full-thickness rotator cuff tear, that's a different story. But in somebody who's 65, it's so common that it would be hard for me to tell them to, you know, to need surgery if they are doing well. And it is fairly common that these patients do get better with physical therapy. Great. Thank you. Yeah, I agree. I mean, I'd follow the algorithm that we have in our paper and go with physical therapy and offer injections. But that's where nuance comes into this. She is 65, and you look in the literature, and physical therapy versus surgery over that first five years, like Dr. Vest has said, generally outcomes seem to be about the same, but it's that five- to ten-year period where those that did not have surgery tend to go downhill some. And so if you wait, say it's eight years later, and she's, you know, 73 years old, and these – correct me if I'm wrong – they tend to do worse as they get older, you know, what do we do in that situation? Has it retracted further, more atrophy, which we expect that it will, and then she's more of a replacement candidate at that point. So I think just having that discussion. But, you know, that would be more probably on a return visit. They have them come back in two, three months and have that discussion. But right off the bat, then generally what we'll do is talk about injections. Now, the other thing to think about is that she does have some mild glenohumeral joint arthritis. She does have some proximal biceps tendinopathy. And I think trying to figure out, is this all just the cuff tear, or does she have other pain generators like we mentioned before? I think just letting your physical exam kind of guide you that way and make sure that it's not just a cuff problem. Thank you. A couple questions from the chat here. How often do you see scapular dyskinesia in these settings with significantly improved symptoms if the scapular kinetics are corrected? So I'm a big proponent of the scapula. I think just having an overhead athlete interest, I tend to focus on the scapula maybe more than others. And so I always look to see if there's any dyskinesis, and that dyskinesis can portend some irritation of the suprascapular nerve. And so I'll kind of go down the path of suprascapular nerve block in those situations, too. But I think it's somewhat of a hard question to answer because we're not just focusing on the dyskinesis with therapy. We're kind of focused on a couple different things, but it certainly is something to keep your eye on as part of the exam, and it could contribute to some of these symptoms that they're having. Great. Dr. Best, I think this question is directed to you. If the cuff is the true problem and she has good active range of motion and fails conservative care, any role for superior capsular reconstruction if the cuff cannot be reattached anatomically? And then does the glenohumeral arthritis increase risk of stiffness post-op? You know, it's a great point. So I have a particular interest in irreparable rotator cuff tear. So I do perform superior capsular reconstruction much, much, much less than I perform lower trapezius tendon transfers and other tendon transfers, partly because of where I trained and partly because of the literature. But there are a lot of options for irreparable rotator cuff tear. So let's say this patient comes back in, you know, a couple years and she has retraction to the glenoid and she has grade three atrophy of her rotator cuff. Then what's the option? Well, there's many options. Let's say she does not have arthritis, because if she has significant arthritis or if she has significant superior migration where the humeral head is close to the undersurface of the acromion, or if there's even mild changes under the acromion and the humeral head is close to that, or Hamada 2 or Hamada 3 changes, then she's not a candidate for these soft tissue non-arthroplasty procedures. Then she would be looking at a reverse arthroplasty. But let's say she doesn't have significant arthritis, then there are a lot of options. One of them, obviously, anybody with an irreparable rotator cuff tear should start with physical therapy, and it's extensive physical therapy, not four weeks of physical therapy, but, you know, maybe three months or even more of physical therapy. And if they fail that, then the options are going from kind of the smallest procedure to largest. Options start with debridement and assessing the other pain generators. So an arthroscopic debridement, maybe a biceps tenotomy or tenodesis, looking at the AC joint if there can be any pain generators there. That's a pretty minimally invasive surgery. It also has the lowest effectiveness compared to some of the other surgeries. Tear capsular reconstruction is used in patients who have an irreparable supraspinatus tear. That's the true indication for it, although the person who designed it uses it for everything. And maybe in his hands it works better for other areas. But the true indication is a supraspinatus insufficiency with retraction. I would say it's pretty uncommon to see somebody with pure supraspinatus insufficiency. Almost always the infraspinatus is involved and sometimes there's more involvement of other tendons. But the supraspinatus reconstruction is good at improving forward elevation and abduction. It's not very good for improving external rotation. So once the infraspinatus is involved, which most cases it is, and I think in this case it already is, then I wouldn't do a supraspinatus reconstruction. I think most people would agree that would not be appropriate. If you were to look at other non-arthroplasty options, then lower trapezius tendon transfer versus latissimus dorsi tendon transfer in the traditional sense was latissimus dorsi. I think now we see more that the lower trapezius is better at improving external rotation. And you do also get some improvement in forward flexion as well with the lower trapezius tendon transfer. So that's what I would do over a superior capsular reconstruction. And obviously there's a lot of other things that go into it, and patient expectations and things like that. But superior capsular reconstruction has pretty strict indications. »» And next question. If the patient progresses to a TSA, would you recommend her to play tennis after the replacement? Also, would you recommend traditional reverse or reverse? »» For sure reverse. So once there's rotator cuff pathology, and if it's a small partial rotator cuff tear, or that's a little different, but once there's significant rotator cuff pathology, then it's always reverse. You can't do an anatomic total shoulder in that sense. And with reverse shoulder arthroplasty, the restrictions are really a 10 pound weight lifting limit forever. Some people will push that maybe 15 pounds. Some people push a little bit more. But the more you do with it and the more intense activity you do, the higher rate it's going to wear out and you're going to need a revision, in particular the polyethylene is what wears out obviously. But they can still get back to activity, maybe some tennis and some golf, absolutely. But I would just tell her there's a 10 to 15 pound kind of restriction on lifting. So be careful with any heavy activity overhead in particular. »» And then someone said, I was always taught that atrophy precluding repair can happen as soon as three months after an acute injury. So should I rush to get those folks to my surgeons? How urgent is it really? »» Yeah, atrophy can happen earlier. We don't really know why it happens earlier in some people and takes longer in other people. It's not common to have significant atrophy, really substantial atrophy within three months. So I would say I love when I see patients on my clinic that have a rotator, I have a particular interest in rotator cuff and shoulder. And I love when I see patients on the clinic who have already done some physical therapy, at least six weeks of physical therapy and they're still having problems from a rotator cuff issue, that's a perfect patient that should be coming to my clinic for a consideration of surgery. So I think if you have somebody that does six weeks or eight weeks of non-operative treatment and they're still having issues from a rotator cuff problem or what seems to be a rotator cuff problem, then you can certainly send them to a surgeon at that time. Or like what was mentioned earlier, if there's a concern for more of an acute process, you can always send those patients too, even if you're unsure if it's an acute on chronic or a truly acute cuff tear, those are always patients that can be sent also. »» Sorry, I know these are a lot of surgical questions here. Do you commonly see routine biceps tenodesis for a routine rotator cuff repair? »» Yeah, there's some debate in that. Now I almost always address the biceps at the time of surgery for a rotator cuff repair. And the reason is, it's right next to the rotator cuff. You're already there. It takes about five minutes or so to do it. I do it arthroscopically. Some people do it open. If you do it open, you have to make another incision obviously. If you do it arthroscopically, you're already there. And I use similar anchors to what I showed in the video. And it's an extra five or ten minutes to the case. And the problem is, I mean, I obviously assess everybody's biceps at the time of their exam. And most people, especially if they're over 50, have some degeneration in their biceps or in their superior labrum where the biceps attaches. And if you leave it and you just do the rotator cuff repair, down the road they certainly have a very high chance of having pain in the biceps at that time. So you might say, well, why didn't I just address the biceps at the time of surgery? It's so simple and easy. There's no real reason to have the very proximal portion of the biceps tendon. It really serves no purpose. You have the short head of the biceps. And when you tenodese the biceps, it's in the groove and you still have full function of the biceps anyway. So I do, and most surgeons I know routinely, very routinely, as in more than 90% of the time will address the biceps. Now if it's a 30-year-old patient or a 20-year-old patient or a young throwing athlete, this is a totally different story. Or if I'm assessing a labrum or instability symptoms, that's different. But in an older, certainly degenerative cuff tears, I'd say almost all of them are getting either a tenodesis or a tenotomy has equivalent outcomes to a tenodesis, and it's just based on surgeon preference. The only difference between tenotomy and tenodesis is really some cramping and some cosmesis of the biceps long-term. Otherwise there's no difference in outcomes whatsoever. And then what rehab protocol do you use for rotator cuff tears? I think you went a little bit into that. In general, most people will start with passive motion, some pendulums or very light motion in the first several weeks after surgery, and they'll be in a sling for usually about six weeks. After that, you progress physical therapy with more active motion. And the goal is, it's kind of in stages, so it's not really a rigid protocol. Once they get past one stage, then they can progress to the next stage. So they can't do any light strengthening. We usually start strengthening with bands before doing more significant strengthening. You can't really get to the strengthening stage until the motion is full. So I always tell patients, you're going to be in the sling for six weeks just doing very light exercises. After that, you're going to be very stiff. And then the goal for the next six to 12 weeks after that is to get full motion. Then you'll progressively build up strength. So I'd say that's kind of a general way that most people do it. And it's a little bit different based on the size of the tear, the location of the tear. If you have a subscapularis tear, it's different. We obviously put restrictions on external rotation if we're doing a subscapularis repair. Or a massive tear, you may have more restrictions on that as well. They might be in the sling a little bit longer. If I do a biceps tenodesis, I don't have them do any active flexion of the elbow for six weeks. So there's kind of multiple things that go into it, but that's a general overview of the rehab process. Thank you. Thank you. And Dr. Bowers, in our last minute here, can you comment on what your favorite orthobiologic to use for both the first case and if it's different for this case as well? So I knew the biologic question was coming somewhere. And we never really got into it because I think in both of these situations, it's not really the ideal person to have that discussion with. I think if you look at the literature for small to medium size partial rotator cuff tears, there is some moderate data for PRP. Just in the last year, there have been two randomized controlled trials showing PRP to be superior to corticosteroid injection. And so we do have fairly high level data, just smaller numbers that PRP can work in those situations. And so that's generally the orthobiologic that I'll discuss. Now when you get into some of the stromal cells and your bone marrow and your adipose, in my opinion, we're just not there yet as far as data goes. There is a thought that maybe adipose would work well for some of these tendon pathologies because it creates a bit of a scaffold to kind of help the tendon heal. But that hasn't been borne out in any literature or anything like that. Jerry Malenga did a study probably close to two years ago now in spinal cord injury patients that have a lot of rotator cuff disease from using their wheelchair. And it was just 10 patients, but they all have significant improvements in pain and function with an MFAT injection. And there are a couple of bone marrow studies out there, but it's still pretty low level data from that standpoint. So generally, I'm not going to jump to those cellular treatments. I'm going to talk with them about PRP, and it's going to kind of follow that algorithm a bit. And we'll do some of the more standard injections, subchromial cotorlax, suprascapular nerve block. We'll get them into therapy. And then if they come back and they're still having issues, then we'll talk about some of the other things that are in the paper. We'll talk about subachromial hyaluronic acid. There's some small studies that show that shockwave therapy can be helpful for some of these tendon disorders, specifically the rotator cuff. And that certainly is minimally invasive and doesn't involve any needles at all. So you could have that discussion. Platelet-rich plasma, like I just discussed. And then there are also a couple trials looking at just dextrose prolotherapy with some needle fenestration of the tendon. And so those are also things that you can discuss on a more, you know, trying to stimulate the tendon to heal, as opposed to just pain relief. So those are all things that I will have a discussion with the patient. I'd hold back on those, just given that insurance doesn't like to cover a lot of them. Prolotherapy and needle fenestration, insurance will cover. And so you can do those. I take that back. Insurance doesn't like to cover prolo if you don't document it correctly. But if you document it the right way, you can get it covered. So that's something that you can do at low to no cost to the patient. That's kind of, you know, a step below some of the other higher biologics. So that's kind of a quick run-through of biologics for these situations. But I think for these two cases, I don't think either of them are the ideal kind of a larger partial acute tear and then an acute on chronic full-width tear. I don't think either of those are really the ones that I'm going to go down that road on. Great. Thank you. So I know we ran a couple minutes over. Just want to give a huge thanks to our guests here.

rotator cuff tears

management

non-surgical options

MRI evaluation

injections

physical therapy

suprascapular nerve blocks

corticosteroids

hyaluronic acid injections

individualized treatment plans

orthobiologic treatment