Rotator cuff tears are becoming more common in younger active patients in their 40s and 50s.
Typically, they are small tears at this time, but what should we do with them? Should we consider surgery? Should we avoid it at all costs?
We talk about some of the things to consider in this episode.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 349: Rotator Cuff Repair Surgery in Younger Patients
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Show Notes
• Quadriceps and Hamstrings Strength Reference Values for Athletes With and Without Anterior Cruciate Ligament Reconstruction Who Play Popular Pivoting Sports, Including Soccer, Basketball, and Handball: A Scoping Review
• Normative Quadriceps and Hamstring Muscle Strength Values for Female, Healthy, Elite Handball and Football Players
Transcript
Student:
All right. We have Brian from California. “Lately, I’ve started to see more patients in their forties and fifties that want to stay active out for rotator cuff repair surgery when they have small tears. Many people on Instagram have stated that this isn’t needed, what are your thoughts?”
Mike Reinold:
This is a real timely question. I thought this was a good one because I know we have at least a handful of them right now at Champion. But, people in their forties and fifties, small rotator cuff tears, obviously their shoulder hurts or we wouldn’t have found out. We wouldn’t have dug into this, but they want to stay active. There’s a small crowd on Instagram that will shame you if you send them to the doctor. That would be bad, that would be evil, that would be negative for them, putting thoughts in their head. And there’s another group that wouldn’t. So, I think the real question is, we’ve had some recent experiences here at Champion with this. What do you guys think? And then I’d actually be curious too, but I don’t want to put Dan on the spot, but I was going to use Dan as an avatar and say, Dan, if in 10 years you got a small rotator cuff tear… How many days a week you work out?
Dan Pope:
Six. I like working out.
Mike Reinold:
I mean, if there were eight days you would do it right?
Dan Pope:
I might, yeah.
Mike Reinold:
Right. So Dan works out six days a week for how many decades? Two decades now?
Dan Pope:
Yeah.
Mike Reinold:
Right?
Dan Pope:
I’m getting older now.
Mike Reinold:
Yeah. And look, you have family, you got recreation, things you like to do, right? If 10 years from now you’re in your upper forties and you have a small tear and it’s not responding to rehab, that sort of thing… Or maybe it is responding to rehab, but just is becoming that cranky shoulder, what do you do, Dan?
Dan Pope:
Yeah, I think about this sometimes because I probably will have this issue at some point in my life.
Mike Reinold:
I didn’t mean to highlight you for that reason.
Dan Pope:
At this point, I don’t know what is going on in there. I would potentially consider getting surgery. I’m not really there right now, so I’m sticking my head in the sand. I don’t know. There’s a long background to this, do you want me to go into that?
Mike Reinold:
Well, I mean we could talk about some of the guys we’ve recently worked with and stuff, but I know these are things that you’ve researched. I know these are things that you look at. I know there are some very vague studies that talk about progression of tears and stuff, so I was just curious your perspective, but I think if you put it in the lens of what would you do if it was you. Based on all the science, I just think that’s an interesting way to look at it.
Dan Pope:
I would consider it. I’d say, yeah, I would consider it, getting surgery. I’d probably wait until it was a little bit bigger. I don’t know if I’d do it like a really small tear, but I think that’s part of the problem. As you don’t really know, I’ve had a bunch of young folks in their forties with a history of some shoulder pain, but they can still lift weights. Eventually, they go to the doctor and they actually have massive cuff tears, fully retracted tears, and they don’t look like they have massive retractive tears.
They’re lifting in the gym still. And that’s odd, but that is the presentation I think you see with these forty-year-olds who’ve been living their entire life and they have shoulder pain, maybe chronic up and down over the course of time. They eventually go to the doctor and lo and behold, they actually have much more than a small or medium tear. And that’s an issue for sure, but it’s not the question the patient had I guess, the person here had.
Mike Reinold:
Well it’s also tough for you, right? You are 10 years away from that, so you still feel invincible, you still feel like… You know what I mean? I can get through that. That’s a tough one, right? Your thought’s interesting though. You probably wouldn’t do it if it’s small. You’d wait for it to be chronic, degenerative, and retracted. Makes sense.
Dan Pope:
Yeah, I wouldn’t do that either.
Mike Reinold:
So, here’s our dilemma and that’s the point, right? Fix this thing when it’s small or wait for it to be retracted and actually have some issues. That’s the part that stinks for this. So I don’t know, Len, you want to start first? I know Lenny and Mike will be some great examples here. They’ve both gone through some recent people that I think fit this exact mold. I’d be curious to hear, with your patients, why they did choose surgery, what the doctor said, what your thoughts were, how they’re doing, that sort of thing. So Len, do you want to start first?
Lenny Macrina:
Yeah, Dan alluded to it a little, and I think you did too, that these do get worse over time usually. There’s probably a small population that can survive. It’s like anything else, maybe a third, you get the rule of thirds or something like that. You try to place your patient in certain buckets and see where they fit, and you get in their head and you see what their pain is. Is their pain responding to rehab? What’s their function? What’s going on with them personally? Stress related? And then what’s the MRI show? How big is the tear? Where is the tear? And then you can give it a course of PT and try to build some strengths pre-hab, so to speak. But I think they do seem to get worse over time, and then you’re dealing with potentially tissue that’s not as good.
And most of these people do elect, at least that I’ve treated… Do elect for surgery, and they do really well. I got a guy right now who’s 50, early fifties, had a small to medium-sized tear, about a two-centimeter tear, which means supra in some of the infra, and he is doing amazing, no pain, full motion, and back to golf in an amazing lifestyle. He completely resolved all of his symptoms and he is happy. And that’s what you want to see, not the person that’s kind of up and down. You do a follow-up MRI and it shows a bigger tear. As you age, as the tear gets bigger, it’s tougher to repair. I’m not advocating for everybody to have surgery.
I’m certainly not the opposite of Dr. Instagram from the question, but there is a time and a place for somebody to go conservative and non-op. But picking the patient appropriately and getting in their head, oftentimes they will eventually have a surgery, and it might be good to catch it early when they’re younger and better tissue quality. But again, it’s going to be different for everybody, and you’re part of the team, you’re part of the team that is in their head trying to answer their questions and is the timing right for them family wise and personal wise, work wise… There’s so many different variables to consider, but there are good, very good outcomes that people do have these surgeries.
Mike Reinold:
Interesting thought based on what you just ended with right there, is that I think that’s another benefit we’ve seen with these people that have elected or are electing to have this type of surgery, is that they’re doing it when they want to do it. They’re controlling the narrative to an extent. And we have one particular one now that’s going to start rehabbing with Mike in, I don’t know, about a month now that’s been planning this for six months, right? He’s like, “Well, I’m going to get as strong as I can. Let me get through the golf season and I’ll tackle this when it’s convenient for me. So that way I prevent it from becoming a problem and less convenient for me in the future.” So that’s another interesting part about getting after it a little bit earlier, is you can kind of control that a little bit. Yeah, Kev.
Kevin Coughlin:
Yeah, I’ll just say having talked to you guys about this, it’s definitely something I’ve changed my mind on in the last few years. I think I would’ve got baited into the Instagram narrative about “this is another sign of aging and it’s a common thing and let’s just rehab it.” I think what you just said and what Lenny was saying about the timing and everything, it’s a shared decision making process with the patient. Dan and I talk about this, but our job is to give them the best information so they can make the best decision for them. So, letting them know that there is a chance that these types of small tears do progress and say you have them on the eval and you’re suspecting a tear. I think something I would do differently that I wouldn’t have done in the past is maybe get them in with a surgeon to have a consult and get some baseline imaging and figure out what size this tear is and the surgeon’s perspective on it and if they think they’re a surgical candidate or not.
So, we’re not totally missing the ball and ignoring the symptom and saying, “Let’s just rehab this, you’re going to get better.” They need to know that this could progress. Because if they are someone like Dan who over the next 40, 50 years wants to continue lifting and staying in good shape, we don’t want to turn a small tear into a large tear, and then their chance of recovery from a surgery is a little worse. Their chance of retearing after surgery could be a little worse. So I think just being upfront with them and trying to share all the information so they can make the best decision possible for them.
Mike Reinold:
If you’re a 55-year-old active person and you’re faced with a decision where, if you avoid this, you might be less active in the future. I think a lot of people… I think that’s what sways people is when you say that here is like, “You haven’t even gotten to retirement yet. You’re not even at that point yet and you have a lot of things you want to do. You got to be careful with that a little bit.” So good point, Kevin. I think you made an excellent point here where it’s different for each person and their activity level, and it’s going to change our mindset with that. So I like it. But Mike, your experience, you’ve gone through this now, got a couple under your belt, at this moment, just being curious, what were their thought processes? What was yours during that? What are your thoughts?
Mike Scaduto:
Yeah, for sure. I think this is a very interesting population, the 40 to 50-year-old with shoulder pain. I think one of the big determining factors is they start to have pain when they sleep and it’s disrupting their sleep, and that’s one of the primary symptoms that I hear them complaining about. And then, generally, these people are working full time, so they don’t have a ton of time to enjoy the activities that they want to do, for example, golf. So then they go out on the golf course and their shoulder hurts and it’s very discouraging for them. So I would say yes, we’re seeing an increase in these surgeries in this population. I’ll just throw in a contrarian viewpoint. I think these are very difficult people to rehab. I think they don’t always understand what is expected of them post-op, to be in a sling for four to six weeks.
Maybe they have young kids, they’re helping out around the house, they’re still trying to work, maybe they’re traveling for work. I think that these are people that we really need to educate about wearing the sling, using all of those post-op precautions. It seems like the surgery and the post-op rehab is always a little bit too slow for them. They want to do this quicker. They’re like, “Hey, how can we speed this up?” And that’s really not the name of the game, especially in these smaller tears. They seem to get a little stiffer early on, and they seem to be a little bit more painful early on. That’s something that I’ve heard from surgeons as well, that those smaller tears tend to be a little bit more painful when they go in and do a rotator cuff repair. So I think there’s a lot of things that we need to talk to them beforehand to make sure that they’re psychologically ready to go through the rehab process and that their family’s prepared for this.
They’re going to need some help. They’re going to need rides to and from PT. They’re not going to be able to drive for a certain period of time. So it is challenging. I think a lot of times these people think that the recovery is going to be really smooth and easy. And shoulder surgery and rotator cuff repairs, it’s pretty difficult for the first four to six weeks and beyond. And when they’re trying to get back into the things that they love, really trying to build out a gradual return to golf program is sometimes difficult. These people want to get back to it as soon as possible. They don’t want to have a ton of restrictions. I’m not trying to throw anyone under the bus here, but I’ve found it to be a challenging patient population to rehab.
Mike Reinold:
Well, it comes back to the point though, that maybe these small arthroscopic ones, they don’t hurt enough, they don’t hurt enough, they don’t get stiff enough, those types of things. They’re younger, they’re healthier, and what we’re doing is we’re putting them on a rehab protocol probably built for 70-year-olds, in all honesty. So, I think our real question is… I don’t think we were really thinking about 40 and 50-year-olds having small rotator cuff repairs back in the day. I think a lot of physicians will treat them just like a 75-year-old with a large tear. So, that’s frustrating for the person too, so they’re like, “I don’t need to go this slow.” I’m not saying they need to go faster, but this is a different population. It’s just something we’re not used to. This is something becoming more common with society now with people being more active and stuff.
It’s interesting. And to Lenny’s point, Lenny said it too. I’m not advocating everybody get surgery either. I’m being more devil’s advocate for it here, but I would say I’d probably lean towards surgery more than not on most active people, but control the narrative. I think that’s probably what leads to success. So yeah, it’s an interesting topic. I don’t think there’s a right or wrong answer here, and what do we do in our shoes? It’s like, well, whatever decision that the person comes up with, our job’s to help them, right? So, we’ll help them maximize non-operatively as much as we can, if that’s what they want. That’s fine, but it’s also probably our job to jump in and say, “Hey, this keeps recurring, let’s be careful.”
And I think just going back to what Kevin said, this is the part that I think ties it all together. When you send them to a physician right away, instead of just putting your head down, it’s not that you’re trying to get surgery right away, but having that baseline or when I call it’s like, “We’re not going to rush into this, but let’s start a relationship with a shoulder surgeon.” And I think they get what I’m saying, right? But let’s just start a relationship so that way, if you do another MRI in a year and you see that it’s retracting or it’s getting bigger, that’s going to probably influence your decision too. So, something to kind of keep in mind. Anybody, Dan, did you have something else you wanted to throw in?
Dan Pope:
I think that’s smart. I think one of the biggest issues we have with these cuff tears is that we don’t really know when they’re progressing. And the problem is if they get too out of hand, then your outcomes are going to be worse, and if it fully retracts, outcomes are probably… I shouldn’t say they’re bad, but the retear rate is high. Even though people tend to do decent, even if it retears, but we don’t want to get out of hand. So I will have my patients that have a rotator cuff tear or suspected rotator cuff tear, I’ll send them to the doc and you probably want to send them to a doc you trust who maybe is not going to cut right away, but tell the patient what we’re planning. He’s like, “We don’t want this to get out of hand.” And then I’ve had this happen at Champions several times.
Someone comes back a year and a half later, “My shoulder flared up.” “Okay, let’s go to the doc, we’ll get it checked out.” I think the problem is that MRI is expensive. I talked to Rob Manske about this, and he has a few docs to do ultrasound, which is really cool because you can… Actually, serial ultrasound that tendon year over year and see what’s going on there, and it’s not that expensive. If it’s a technology you have access to, I think that’s a great idea because the big problem is that we don’t know when they’re progressing or how fast they’re progressing. If we have pain, maybe that correlates. If it’s a worse tear or there’s retraction or there’s multiple tendons involved, we know those progress faster. Otherwise, we don’t really know. So if you can establish a relationship with a doc and actually get some objective info, I think that really helps.
Mike Reinold:
Awesome. Great stuff. I agree 100%. And don’t forget, we talk about how rotator cuff tears are oftentimes recurring. Meaning they’ll have a recurrent tear. Well, not so much in the small ones, keep that in mind too. So outcomes after a small tear are often better here too. So again, just another factor to throw in there. Great stuff everybody, great episode. I think that was awesome. Hopefully that helped, Brian. For everybody, you’re going to start seeing more and more of these people if you haven’t already. So, this is how we handle it here. We don’t push anybody in any direction, but we help guide them with, “Hey, let’s just make sure we’re covering our bases.” And I’ll say a couple of the people that we’ve talked about today that we’ve sent to the doctor, I think we’ve been surprised. I know I was on the one that’s about to come in a little bit, on how the doctor was like, “Look, this isn’t a rush, but you should do this.”
So that means they see something in there that they don’t like. So, keep that in mind. Sometimes they’ll be like, “Let’s keep an eye on it,” that sort of thing. But when they say that, in my mind, I’m like, “I’m glad we did this because they think this is going to get bigger, quicker,” or something like that. I don’t know. But again, we send them to good doctors that we trust, that aren’t abusing the system and looking to cut on everybody like Dan said. Anyway, awesome stuff. Please keep subscribing to the podcast if you liked listening to this and listening to the answers to our questions. Apple Podcasts, Spotify, whatever you do, please review us, rate us, subscribe, whatever you do, and we’ll see you on the next episode. Thanks so much.
