On this episode of the #AskMikeReinold show we talk about working with patients with full-thickness rotator cuff tears, some of the treatments we would focus on for those trying nonoperative physical therapy, and if they can even avoid surgery at all. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 197: Treating Full-Thickness Rotator Cuff Tears Nonoperatively
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- Can Physical Therapy for Rotator Cuff Tears Prevent Surgery?
- Getting Back to High-Level Activities with an Irreparable Rotator Cuff
- Can You Have a Rotator Cuff Tear and No Symptoms?
Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about treating full- thickness rotator cuff tears non operatively.
Fernando: Brian from New Jersey: “What has been your experience working with individuals, specifically non-athletes, with medium to large size, full thickness rotator cuff tears, non-operatively? I feel some surgeons instill fear in some of the patients that I work with based on MRI findings where they could prolong surgery, or may not need it, once they begin PT based on goals.”
Mike Reinold: All right, so let’s call it a full thickness tear in a non-athlete. I actually liked that because that’s more important in this world, there’s way more. Full thickness tear. How often are we successful at non-operating? Let me ask a question. How common do we think that is? How common do we think full thickness tears, in the general orthopedic population, is?
Dave Tilley: I’ve seen a handful over my young career.
Lenny Macrina: I’d say somewhat common. Whether or not they’re symptomatic or asymptomatic, yeah.
Mike Reinold: Right.
Lenny Macrina: Definitely.
Mike Reinold: So, probably not uncommon as we age, right?
Lenny Macrina: Right.
Mike Reinold: This is probably an attrition type thing, as we get there. So that brings up a whole other question, is there a whole lot of different types of full thickness tears? You can have a small full thickness, a big full thickness. I think that’s actually a big part of this question, but why don’t we start from there? So, who has experience with non-operative full thicknesses that have done well? Probably in college right?
Lenny Macrina: Who’s got a labral tear and bursitis?
Mike Reinold: So what do you think, Len, why don’t you start off? What’s the key, to you, for somebody that has a full thickness and we’re trying the non-operative, what’s the key to you, to make sure this is successful?
Lenny Macrina: Yeah, I mean, obviously they’re coming to you probably because they’re in pain. So I could say if they’re not in pain, leave it alone, but they’re probably having a functional issue. Meaning they have pain, and probably some loss of motion, I’m going to assume. They’re just not going to go into the doctor and get an MRI on their shoulder, they have something going on, limiting themselves. So, if they have pain, we got to try to calm their pain down and if we can calm their pain down, can we get their function back? If they’re coming in with a big shrug, if they have a big shrug, not a good sign, but you can still get people stronger getting the cuff strong or the deltoid is stronger to overtake, overpower what is probably torn, which is a cuff.
Lenny Macrina: So, I would say get their pain to calm down, get them as strong as possible and then make a decision. Some doctors, as the person who sent the question says, they put some fear in there, however they word it. Maybe not all doctors do that, I think there’s some doctors that are very educated in how they talk to their patients, but if that doctor knows the risks involved of that person, their comorbidities… In the research that’s something that does show, people can function with a torn rotator cuff and sends them into rehab. We have to get their pain under control and then work on a general strengthening program and instill confidence in that person that we can get them better. I’ve seen cases that have improved and let’s now take on this challenge and let’s try to get them functional again. So I don’t know, very simplistic form but, Mike?
Mike Scaduto: Yeah, I think the fear aspect coming from the doctors’ is definitely important. It may not be exactly what the doctor says and they may not be purposely trying to instill fear. But if someone tells you, a full thickness tear in your rotator cuff, the patient may just shut off after that, then they automatically think that they need surgery. So, I think… Then they come to us, and they’re very concerned about that, because they think the surgery is going to be really tough recovery. But we may be able to kind of spin what the doctor said or kind of give them hope that they may be able to recover from this and that we’ve seen people make progress with that and I think that goes back to being able to make minor changes in their pain or minor changes in their function, as much as we can, early on. Kind of gives people hope and then also setting expectations for them. It may just be very, very minor progress, but trending in the right direction, will give them kind of hope that this could go better than they think.
Lenny Macrina: I think what Mike said, that the amount of tissue involved is critical. An MRI is going to kind of pick that up, but I mean a smallish tear, you’re definitely going be able to avoid surgery. Right? And this atraumatic… We’re seeing more research that’s showing that atraumatic chronic cuff tear has a chance to heal, if not, maybe has almost the same chance as surgery, because when they have surgery and we fixed the cuff, we do second look ultrasounds or MRIs, in between probably 5% and 90% so the range is huge, because that’s what the research is saying, has a re-tear one to two years after the surgery. So almost everybody re-tears their cuff, after having a surgery to fix the cuff. So, why are we having this 20 plus thousand dollars surgery, when they’re probably just going to re-tear in the long run, anyway?
Mike Reinold: I’m going to throw a curve ball into this discussion then, because if you look at the people with the percentages that don’t do well with surgery, it’s the larger, more chronic, more degenerative over time. So let’s ask a question again now. You have a small tear now, right? That’s non painful-
Lenny Macrina: Does it get worse? Yeah.
Mike Reinold: To me, that’s one of those injuries, rotator cuff tears, that if we’re just saying it’s asymptomatic, ignore the MRI and just let them continue to do things. That is definitely the type of injury that gets worse over time. And then you go to the point where now you have pain, now you have some in there. So, I’m not saying… I’m a big believer in non-operative rehab in this. I’m pretty sure the literature shows that you probably have a greater than 50% chance that you’ll do well with non-operative, if you get it early enough. So it’s an interesting one though. So, what do you guys do? I mean, Dan, if you’ve got something else, jump in too, but what if there’s no pain? What do we do?
Mike Scaduto: I don’t know if they would go to the doctor, right?
Mike Reinold: Yeah, that a maybe, that’s a good point.
Mike Reinold: That’s a good point.
Lenny Macrina: I don’t know and that’s going to be the one reason why they have pain and then how long they… Because they have pain for a day their not going to the doctor. They have pain for months, now they’re going to the doctor. It’s going to be last ditch, “I have a frozen shoulder because…” something.
Mike Reinold: That’s true, yeah.
Dave Tilley: Dad, I love you so much. It’s a perfect example.
Mike Reinold: But do think your dad watches the podcast?
Dave Tilley: Absolutely not. Someone’s going to pass it along to him.
Mike Reinold: I know my mother does. I know Lenny’s mother does. Every now and then Lenny… Good old Janet will give us… What’s up, Janet?
Mike Reinold: They’re always watching but sorry, again. All right, Mr. Tilley?
Dave Tilley: My dad’s story is exactly what we’re talking about, where these people don’t go to PT sometimes. My dad is a great guy, he played softball 10 years ago on slow pitch league. And he was, “Oh, I’m going to get back out there and play.” So my dad has zero background for this and he goes out and he goes super hard for three hours, in the outfield and then pitching, which is not fast pitch. He texted me and he’s like, “Hey, I think my shoulder is a little bummed. Can you help me out? I just need some exercises.” And I ask him to move. He’s like, “No, it’s fine, I got a little motion.” Had a huge shrug sign. He can’t move his arm at all. He’s like, “Yeah, it’ll work itself out.” So many people don’t have a problem until something flares up for a day or two, or they can’t raise their arm, they’re like “This is probably a problem.” But then three weeks go by and they’re like, “Okay, I’m better.”
Lenny Macrina: Did he have surgery?
Dave Tilley: No.
Mike Reinold: Right. Wow.
Dave Tilley: He didn’t go to PT.
Dave Tilley: The reason I bring it up, is I told my dad, I’m like, “Okay, this is a warning sign. You probably had symptoms before or had issues before.” And I wasn’t going to let him blindly not do anything. I was like, “You should do these exercises. At least warm your arm a little bit. Maybe try to add a couple of exercises in.” But like you said, you can’t leave these people like, “Nothing is hurting or nothing is lost motion.” So it’s just like, “You’ll be fine. Keep going.” There’s a reason behind why the cuff is probably irritated, whether that’s a structural thoracic kyphosis or something like that. Or they just get super excited and go play three hours of softball.
Mike Reinold: That’s probably what happens with most people, they have chronic postural adaptations, chronic degenerative changes of their tissue. And then they go pretend that they’re 10 years younger than they really are and they do an activity they haven’t done it a while. And that starts to kind of cascade a little bit. So, I think that right there, gives you the answer that we shouldn’t just ignore these and we shouldn’t be content with the fact that they have an asymptomatic MRI and that’s normal. That’s not normal. If it wasn’t torn when they were born… Did that just rhyme? Wait a little, let’s come up with something. If it wasn’t torn, when you were born…
Dan Pope: It’s not the norm.
Mike Reinold: You must..
Dave Tilley: Grab the bull by the horns.
Mike Reinold: You must grab the bull by the horns. It’s t-shirt time.
Dave Tilley: This little bull with a cuff tear.
Mike Reinold: I mean, if it wasn’t that big of a deal, then we wouldn’t have a rotator cuff. So it’s not supposed to be torn. So I think that’s kind of the point right here. So if somebody has this or somebody has a small tear, there’s definitely some things we can do. Let’s shift gears for a little bit here and try to conclude with this. What is our rehab strategy on this person? What is the key to their success? Who wants to jump in?
Mike Scaduto: Yeah, I think you got to look at their function and obviously do a full assessment of them, but I think it’s going back to the basics of restoring as much passive range of motion as you can, restore active range of motion, isolated strengthening of the rotator cuff and the scapular muscles and then go back into some more functional type training. If they are doing any training now, that gives them symptoms, you modify in the short term and then gradually progress them back to what they want to be able to do.
Mike Reinold: And we’d probably see this more and more with people in younger generations, probably now. Was fifties now, probably forties, maybe even late thirties, in the aggressive fitness athletes, Dan. Because they’re having these rotator cuff tears. Again, they’re hopping on Instagram and saying that, “I should work through this.” What do you tell those people?
Dave Tilley: It’s tough. It’s two different populations and I think we get flamed sometimes for trying to pull athletes back, because it’s supposed to be this hopeful message that everyone can heal and adapt and get better. It’s challenging because I think it’s similar, probably, and we don’t have the research to support this yet, but to… Let’s say, a baseball player, where they’re going to have asymptomatic cuff tears and labor pathology, sooner than the general population. So, it’s a tough thing to answer. Because I’ve definitely worked some people in their twenties that have pretty bad cuff tearing and the thought is, “Can I continue? Should I stop?” And then, here’s the thing, most rotator cuffs, over the course of time, will tend to worsen. You have this whole idea of adaptation, “Is my tissue adapting because my pain is going away?”
Dave Tilley: Well, I’ll tell you what, your pains go down and you can get stronger but your tissue can also be getting a little bit worse. So that’s pretty challenging. I think that looking at symptoms is going to be important, but doesn’t give you the whole answer. I will tell people to go in every few years to maybe get it checked by the doctor again and see if the MRI is not worsening. The only reason for that is because there is a potential that you could get a retracted tear, potentially get more arthritis and not be able to get the surgery that was better. So reverse total shoulder versus shoulder replacement. I see people that are in their sixties that are doing high level CrossFit to have a good amount of arthritic changes in their shoulder. And at that point it’s kind of like, “What do I do? What do I not do? Is pain a guide? Is it not a guide?” And I don’t think we have all the answers.
Mike Reinold: Yeah, we’re definitely getting there. And then I would just share one last thing with my experience with some of this. Back in the early part of my career, we used to do a ton of elderly people with massive rotator cuff tears that were irreparable. And that’s the one thing that people don’t get about people like Dr. Andrews down in… Well, he was Alabama. He still did surgery on… He treated everybody in the community too, not just the pro athlete guy, so he had a ton of people just massive chronic rotator cuff tears that were irreparable and we had great success. We actually… I mean, it depends on how you define success with them, but we got them lifting their arms again, we got them pain-free, we got them doing really well. We always went back down to this whole suspension bridge concept that we always talk about. Who came up with that, by the way, is that Rockwood? I don’t even remember now.
Lenny Macrina: The Rockwood and Mattson book?
Mike Reinold: I don’t even remember. So the suspension bridge concept is, you think about, you get your shoulder and you’re looking at it from above, if you think of a suspension bridge. As long as your anterior and your posterior rotator cuff are really, really strong, it’s okay if you have a tear on the superior aspect or supraspinatus because those two can kind of steer the ship. The anterior posterior cuff can allow them to elevate their arms still. And we got a lot of people super functional by just getting their anterior posterior cuff as strong as we can. So, obviously, again, the more massive of a tear you have, that’s a problem. It starts extending into the infraspinatus.
Mike Reinold: But then man, you better focus on the teres minors. So you better know different exercises. Better read the article that we’ve published in JOSBT that talks about these different EMGs, because you have to be able to hit that teres minor a little bit more, for example. So, there’s definitely things you can do. So I guess to answer, yeah, you can definitely be successful. I don’t think you want to be that guy riding your high horse right now, saying that, “Nobody should get surgery!” “MRIs and being asymptomatic are normal.” I don’t think we want to go that far down the road. That’s a little too far with that. But yes, we can be successful. Mike, what’ve you got?
Mike Scaduto: Just got to throw a wrinkle in there. This is a question that I kind of have. Where do you guys think biologics… Gene injectables like PRPs, and even anti-inflammatories, corticosteroids and cortisone, kind of fit into the rehab process for someone who has a medium to large cuff tear?
Mike Reinold: Good question. So, I’ve actually… At the meetings I’ve been speaking at recently, there’s been a lot of good physicians that are big on the biologics. The guys out in Chicago at Rush are doing a really good job. Brian Cole, is kind of one of the leaders in that and I’ve heard him speak now a few times on biologics. And then obviously, anyone jump in if you had experience. But I think right now like the results are getting there and I think the idea and the concept of biologics on these people, are there. I don’t know if it’s there yet. But, another thing to consider here, if you have a full thickness retracted tear, I don’t think biologics are going to help with that. So, I don’t know how much biologics are going to help with a big full thickness retracted tear. Maybe if you have a partial thickness undersurface, I think, is what we’re going to look at. So, good question. I don’t know if it’s going to necessarily help that. It might help with the reconstruction or repair.
Lenny Macrina: That’s what I was going to say, is to augment it with the repair. So if they can do some kind of PRP or STEM cell, which I don’t think that I’ve seen it’s working, yet. Maybe we need…
Mike Reinold: I don’t know if we know yet.
Lenny Macrina: We don’t know yet.
Mike Reinold: The concept’s there and biologics are getting better. I think that’s the other thing to do. As FDA regulation stuff changes, that we’ll get there.
Lenny Macrina: And then even also, almost like an internal brace that we use for ankles and elbows and we’re starting to use non-human tissue. Collagen scaffolding for these tissue types that failed, in the nineties and early two thousands, trying to use different materials. And I think we’re revisiting an old concept and seeing promise. So I think there’s something to keep an eye on. Superior capsular reconstructions, things of that nature. We have tears in areas that were never repairable before and function was lost. We can now use some of these newer materials, and there’s newer promise, so we’re definitely making gains.
Mike Reinold: Awesome. Great question. Thanks so much for asking that. If you have a question, head to mikereinold.com, click on that podcast link and you can fill out the form to ask us questions. Ask us anything you want, we’ll be happy to try to get it on a future episode. Thanks!