Rotator Cuff Repair

Episode 3 - Rotator Cuff Repair

Dr. Eric Chehab: Welcome to IBJI OrthoInform, where we talk all things ortho to help you move better, live better.  I'm your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day. 

Today, it's my pleasure to welcome Dr. David Hamming, who will be speaking about the rotator cuff. As a brief introduction, Dr. Hamming graduated from Princeton University in 2001 with a degree magna cum laude in molecular biology. He attended Vanderbilt University, School of Medicine in Nashville, where he was selected to the Alpha Omega Alpha Honor Society and graduated in 2005. He completed his residency training at the University of Minnesota in 2010. He then did his advanced surgical fellowship training at the Steadman Hawkins Clinic in Colorado in 2011, which is considered one of the most prestigious sports medicine, surgical training programs in the country.

In fact, as a fellow, Dr. Hamming worked with the Denver Broncos during the Tebow years and the Colorado Rockies. Since completion of his fellowship, Dr. Hamming has been an attending sports medicine surgeon at Illinois Bone and Joint Institute specializing in arthroscopic surgery of the knee and shoulder.  He is one of the team doctors for the Chicago Wolves. Dr. Hamming has helped thousands of patients recover from injury and return to an active, productive lifestyle. So David, welcome to OrthoInform and thank you for being here. 

Dr. David Hamming:
Thank you so much, Eric. It's a pleasure to be here this morning. 

Dr. Eric Chehab:
So let's get right into it. We're here to talk about the rotator cuff. Let's describe the rotator cuff for our listeners. What's the anatomy? 

Dr. David Hamming:
The rotator cuff is really a group of four tendons that originate off of the shoulder blade, the scapula and blend together and insert on the humerus, to really, hold together the shoulder joint. People oftentimes call it by different names. They call it the rotary cup or, or I'm sure you've heard all the different terminology, but it's really a cuff of tissue that's blended together with four tendons. 

Dr. Eric Chehab:
So these four tendons work in synchrony with each other, they work as a unit, correct?

Dr. David Hamming:
Right. I tend to tell patients that, they're the fine tuning muscles around the shoulder, then much of the strength comes from your pec tendon, your lat tendon, the big muscles that you see, when you look at bodybuilders, but the rotator cuff, is the fine tuning muscles that help a positioning of the shoulder.

Dr. Eric Chehab:
If we had to describe the function of the rotator cuff, which can be a little bit difficult, we talk in medical terms about it being a humeral head depressor, but in layman's term, what does that mean, for the function of the rotator cuff?

Dr. David Hamming:
I think of it as, not even a depressor, but a compressor. So it's holding the socket together by taking the ball of the humerus and compressing it into the cup called the glenoid. And it's by holding that ball centered in the glenoid, that allows us the great range of motion that we have, and the ability to, to do power, overhead and away from our body. 

Dr. Eric Chehab:
What are some of the signs that patients might have that something's wrong with their rotator cuff? 

Dr. David Hamming:
Certainly one of the presenting symptoms to us is when they come in with pain and that can be either a chronic presentation, it's been getting worse throughout years, or it can be more acute if they do something where they are starting the lawnmower, the snowblower, depending upon the season and they feel the sudden twinge in the shoulder. 

Dr. Eric Chehab:
And with some of the other symptoms besides pain, for instance, if there is a tear of the rotator cuff or the rotator cuff is not working normally, what are some of the other signs and symptoms that they'll have pain is number one–

Dr. David Hamming:
Right, so their symptom, their presentation complaint is usually the pain. What I look for on my exam though, is more weakness. And there can be lots of different reasons to have shoulder pain. You can have bursitis, tendonitis, variations of what we call impingement. But the weakness is really what indicates to me that there could be a real problem with the rotator cuff.

Dr. Eric Chehab:
Now, you and I both see it, where patients come in with that type of shoulder pain, and we're trying to distinguish if they have a rotator cuff tear. There are many, many problems of the rotator cuff– tendonitis that you mentioned, the impingement that you mentioned. But you feel that weakness is a distinguishing factor. So do I, but let's say someone has a very severe rotator cuff problem. How do they present? 

Dr. David Hamming:
Sometimes they can't even move their arm. They either struggled to get it above shoulder level. I looked for something that I call hiking and I think the therapists see that a lot. When patients present with shoulder problems, they move more through their shoulder blade joint with the chest wall, rather than through the shoulder joint, the glenohumeral joint itself.

And then when the tear is really severe, patients present with what's called a pseudo paralytic shoulder. And if you break down that terminology, it really means that it looks like they're paralyzed, but falsely so, because it's not that the nerves don't work, it's not that they have true paralysis, it's that the tendon is disconnected and as hard as they try to, to fire those muscles, it's disconnected and will never generate the power to raise it overhead.

Dr. Eric Chehab:
And I also find, I'm sure you do too, that one of the things that brings people into the doctor's office is sometimes the weakness and the functional problems that they have, but most commonly the night pain.

Dr. David Hamming:
Night pain– that’s exactly right. Whether it's inflammation, a real tear, the shoulders are notorious for causing troubles with sleeping.

Dr. Eric Chehab:
Do you have any idea why? 

Dr. David Hamming:
Truthfully, I do not.

Dr. Eric Chehab:
I don't either and every person comes in with it and I just don't know what causes it. I don't know whether it's hormonal or positional or blood pressure. I just don't know what causes it.

Dr. David Hamming:
I think some of it must be positional because as you know, in postoperative patients, particularly they tend to sleep better sitting upright and well, I'm sure we'll get into this later, but you know, the recliner and things like that, where their shoulder is not quite as supine as the rest of the body, but, right.

Dr. Eric Chehab:
Right. And then in terms of the diagnosis, you mentioned some of the physical exam findings that they may have pain with certain maneuvers, they'll have weakness with muscle testing, but what are some of the other ways that we can diagnose rotator cuff injuries? 

Dr. David Hamming:
Well, certainly we in orthopedics rely a lot on imaging. I always start with plain x-rays or radiographs, and that serves twofold. One is to rule out other things that could be presenting similarly, like arthritis, and the second reason is that we can see how the ball is sitting in the cup and to make sure that it is being centered, that it's not trying to escape out the top or out the front, and to see if there's any evidence of some chronic rotator cuff problems as well, where we see that there's some spurs forming in different locations. 

Dr. Eric Chehab:
So x-rays provide a lot of information for the rotator cuff, even though you can't visualize the rotator cuff directly. But you can visualize the rotator cuff with other imaging modalities. 

Dr. David Hamming:
Yes, certainly MRI would be considered the gold standard to image the rotator cuff. There are certainly indications of using an ultrasound as well to take a look at the rotator cuff. If I'm concerned about the rotator cuff, I virtually always send them for an MRI with the appropriate indication.

Dr. Eric Chehab:
And you and I both see this all the time. An MRI comes back and patients are phenomenally concerned about a report that reads ‘moderate grade partial thickness rotator cuff tear.’ Take our listener through the significance of that read because that seems to be the thing that freaks most people out.

Dr. David Hamming:
Right. I try to actually talk a little bit about that beforehand so that they don't happen to see the report before I have a chance to, to explain it. Because you're exactly right. People see the word ‘tear’ and they're thinking that they're going to need to have surgery, whereas, to me, a partial thickness rotator cuff tear can really just be some natural aging in a lot of cases.

It can be a true injury too, but it's not completely detached, which is an important factor when I consider the treatment options for them. Because, there's plenty of patients that have a partial thickness, rotator cuff tear that do quite well. And hearkening back to my experience with the Rockies, there are plenty of Major League pitchers that have abnormal looking MRIs with their labrums and their rotator cuffs and everything. And they're out there throwing over 90 miles an hour without pain, doing quite well. So a partial thickness, rotator cuff tear is something to certainly treat, but not necessarily to operate on.

Dr. Eric Chehab:
Right. There was a study by Andrews looking at Minor League Baseball pitchers, and who are all throwing hard. None of them had shoulder pain and 85% of them had labral injuries. 90% of them had partial thickness rotator cuff injuries, and none of them needed any treatment actually because they're all throwing hard as can be and didn't have any pain. And his conclusion from the study was if you want an excuse to do surgery, go get an MRI. So the MRI is incredibly important for interpreting the rotator cuff. But people should expect that it's not going to come back saying normal MRI.

Dr. David Hamming:
Exactly right, and I always put it in perspective for the layman. Who's not a Major League pitcher that if we were to MRI their other shoulder, it could look very similar and they're not here to see us for their contralateral side. 

Dr. Eric Chehab:
So I guess the lesson is there's clearly a lot more to the diagnosis of a rotator cuff problem than just the MRI findings. It's obviously the whole picture of pain and weakness, plus the findings from the MRI that can be helpful. With partial thickness, rotator cuff tears, I try to describe it sometimes as a thinning of the tendon. And for instance, if we have a carpet that's been treaded on, a radiologist might come in and instead of saying, ‘Oh, your carpet looks a little bit thin,’ they might say, ‘Oh, you have partial thickness tearing of your worn carpet here. And not that it's torn completely. But just thinned a little bit.’ But obviously the rotator cuff can tear and the muscles can pull away from the bone. So let's talk about these types of tears.

How do you categorize rotator cuff tears in your practice? 

Dr. David Hamming:
I think that there's a lot of different ways that you can categorize them. But the two that I think are most important are acute versus chronic. The blood supply to the rotator cuff is not that great. So there is a natural tendency that with time, for it to, as you said, show some wear and show some tread, and so the chronic presentation where they've had some pain for a little while and it's bothering them with sleeping, but they haven't had an acute injury event. Uh, that is certainly one type of tear. The second tear I look for is a more acute injury, where they fall down the stairs and they grabbed the railing, or they start the snowblower with a big crank and their arm goes pop. The acute injury can happen even in the younger population, whereas the chronic injuries, we tend to see more in the fifties, sixties, and older. But I've seen patients and as I'm sure you have in their thirties that have that as acute injuries. 

Dr. Eric Chehab:
Right. And with the degenerative tears, it's kind of part of life. If you look at the natural history studies of rotator cuffs, you know this data better than me. There's a certain incidence of degenerative tears as we age. 

Dr. David Hamming:
Yeah. I'm aware of a study that shows that, you know, when you get to your eighties, um, greater than half the population has a rotator cuff tear– and that doesn't mean it's symptomatic. 

Dr. Eric Chehab:
That half really doesn't know they have it. And so I will explain to patients that it's a natural progression for the rotator cuff to pull away from the bone, to tear away from the bone. But if it's over a gradual process, there's a means for the body to compensate.

Sometimes I’ll even use the four engine analogy on a 747. I remember saying it's like a 747. And someone said, you're calling me a jumbo 747 and I said, I said, no. Well, you know, a 747 plane has four engines. If one of those engines drops out, the airplane can still fly. And likewise, your rotator cuff has four muscles.

And if one of those muscles drops out, the shoulder can still work. It can still fly. It just may not have the power of the thrust, which as you do get older, you may not miss it as much and may not even notice it. 

Dr. David Hamming:
And with the chronic scenario, if it's happening over years, rather than one day, your body has a way of compensating and re-training itself to take up the slack. Whereas if it happens acutely, that can be definitely more of a challenge. 

Dr. Eric Chehab:
When we are talking about treatment for rotator cuff injuries, the two treatment options are generally non-operative versus operative treatment. And there are lots of variables that go into that decision.

I think about them in terms of the patient characteristics and the tear characteristics. I think about age and activity and pain and function for the patient. So speak to each one of those, let's start with age–

Dr. David Hamming:
So age is certainly a factor. I look at the patient's physiologic age more than necessarily than their chronological age, as I'm sure we do in, all of our patients, but particularly with rotator cuff tears, because their demands that they want out of the shoulder, the health of their shoulder in general with the biology, um, will affect how well they can compensate, but also how well it can heal. Because if we do proceed with the surgery and we make the pictures look perfect, that doesn't necessarily guarantee that they're going to be able to heal it. Uh, so age definitely plays a role in that mainly because of the biology and the blood supply.

Dr. Eric Chehab:
And then if we look at activity demands... 

Dr. David Hamming:
It is a natural tendency that as patients age, that they demand less out of their bodies. Again, I take that on a patient by patient case, because there's going to be people that are in their eighties that want to go play tennis and we need to be able to get them as close to that performance level as they can.

Whereas there's plenty of laborers that have specialized activities that they do overhead such as electricians and other people that need to do a lot of overhead work that we need to make sure they can get back to those jobs as well. 

Dr. Eric Chehab:
Right. And then, some of the tear characteristics in terms of the size of the tear, the number of tendons

Dr. David Hamming:
My experience has been that the pain that patients that are in doesn't necessarily correlate to the size of the tear.

Dr. Eric Chehab:
That's such an important point, right? I mean, we see that all the time. 

Dr. David Hamming:
And I think that sometimes the more painful tears are actually the smaller tears and, I don't have a great physiologic reason for that, other than the fact that maybe some of the fibers that are still left in tact are just seeing so much different load because they're being stressed beside it.

But the size is important for both helping to regain their strength, as well as to help predict their ability to heal it. Um, but not necessarily with their pain, because virtually all orthopedic interventions, surgical, or nonsurgical, can help improve a patient's pain. Right. But when we come time to talk about the size, I think that's more predictive of healing potential and strength. 

Dr. Eric Chehab:
So the bigger the tear, whether involves one tendon or two tendon or it’s farther away from where it belongs. Um, then the bigger the tear, or the farther away it is, then the less likely they will recover full strength. And the less likely that it will actually heal after it's repaired.

Dr. David Hamming:
That's right. So some of the data that I'm aware of, if it's about one centimeter, which would be considered small, uh, that has about a 90% chance of healing. And then as it gets out to where you have three to five or greater than five centimeters, which are considered massive tears. Now less than half of those are going to completely heal. Now sometimes they heal with a spot weld. And so you do regain a lot of strength and function because you do get partial healing. But if you were to say, well, is this truly fully healed? That's not nearly as successful when you're dealing with these massive large tears. But this point I always stress to patients is that, that doesn't mean that clinically they don't feel better.  So they should definitely see improvement, particularly with their pain. 

Dr. Eric Chehab:
So even a partial healing response, where the tendon doesn't fully heal, but a part of it does, will typically result in pain relief and improved function for the patient. 

Dr. David Hamming:
Correct. One of the questions I get often is, ‘well, how do we know if it heals?’ and ‘Do we need to re MRI it to see how it looks?’ And, I always tell them, first of all, a surgically repaired shoulder never looks normal, so it's never going to say completely healed or it looks perfect. And so, uh, so I tend not to re MRI patients unless they really have symptoms. I tell them we base their healing on how well they're doing clinically.

Dr. Eric Chehab:
Let's go for sort of the easy ones for the non-operative treatment, and then the operative treatment. I think an easy indication for someone who's going to be treated nonoperatively is someone who incidentally, by accident finds out that they actually have a rotator cuff tear.

Like for some reason they had a shoulder MRI, and there's a tear of the rotator cuff that they didn't even know they had, they're an older patient, perhaps are well compensated. It's if they were having any discomfort, that seems like a no-brainer to give physical therapy a try.

Dr. David Hamming:
I’d start with some physical therapy. If their pain seemed to be flaring, I'd offer them an injection. We'd do some anti-inflammatories, go that route for sure. So, as we talked about before the partial thickness tear is virtually any initial presentation of that, I would start them non-operatively, right, and then follow them out to see how they progress.

And then for other non-operative candidates, I think it's really individual and how they presented. I have patients that come in with big tears, but they've been more chronic and they can raise their arm overhead. And if you test their strength, they're pretty darn good. And I’d tell you, you know, if you look like this after we repaired it.  I'd be pretty happy. And I realize you're not perfect, but I'm not sure we can make you that much better. Right. Right. 

Dr. Eric Chehab:
I mean, it is so interesting about rotator cuffs because you can have the exact same MRIs on two different people. And one person can literally throw a baseball at 70 miles an hour and throw batting practice.  And the other person can't raise their arm, is in insufferable pain. And their MRIs can be absolutely identical. So it's not just anatomy. There has to be something about how the nerves work, how they can compensate for it, because if it were just anatomy, they should have the exact same function as well.  So it's a totally interesting problem. That's why I like doing this.

Dr. David Hamming:
Year after year, that’s why there's so many studies that are presented favoring, both non-operative and surgical intervention, because there's no right answer. It's an individual treatment. 

Dr. Eric Chehab:
There are a couple of slam dunk indications for non-operative treatment and slam dunk indications for surgery.  And I think of a slam dunk indication is someone younger in their forties or fifties who has an acute injury and has a rapid dysfunction of their shoulder from the injury. And they have a rotator cuff tear in their MRI. And those do pretty well. 

Dr. David Hamming:
They do really well, actually. Yeah. The healing potential is good. In general, their biology is pretty good. That tendon hasn't degenerated that much. The blood supply we can supplement some with the techniques that we use and, they have good healing potential, and they're usually pretty motivated to get better.

Dr. Eric Chehab:
And then obviously the gray area that we talked about is where we individualize the indications for surgery. 

Let's go to the surgery. It's evolved over time. And so take us back to how rotator cuff repairs were done. Let's say 30, 40 years ago, and how they're being done currently today.

Dr. David Hamming:
The goal of the surgery is to restore anatomy. So there's certainly surgeries that we do that alter anatomy and this is one where we're trying to restore anatomy. And so, the general principles have pretty much stayed the same. And I think you could maybe even make an argument that our current techniques have gone back to some of the initial principles or the old open techniques, but certainly the surgery started with an open incision, kind of a sabre incision is what we'd call it over the side of the shoulder and get maximal exposure, see what you're there to repair. And with the advent of arthroscopy, we've been able to minimize the, at least the skin incision, and the invasiveness of that surgery.

And in my personal opinion has actually improved the surgery, uh, because, uh, you can get better visualization arthroscopically rather than through one big hole. You can look all around the shoulder with a scope and really assess the tear, be pretty pinpoint with where you want to put your implants and limit the amount of collateral damage of the surgery. 

Dr. Eric Chehab:
It seems most of us are doing these rotator cuff repairs, arthroscopically or arthroscopically assisted. And it's a rare case where we're doing an open repair and it does seem to help with the recovery. And again, we're restoring anatomy. We're sewing that tendon back down to the bone.

But any sort of routine augmentation for the repairs?

Dr. David Hamming:
I try to make sure that the footprint, the part on the humeral head where we're repairing it has a pretty healthy looking area to dock the tendon into the implants that we use are actually fluted now.  So the bone marrow is coming out through the anchor and really helping that, uh, that healing potential. So. I think that a lot of, uh, you know, grafts like people use skin grafts or they used to use porcine or pig graphs to help augment areas. I personally have not really found the need or indications for that.

Dr. Eric Chehab:
Right. I agree. And so let's take it from the patient's perspective. So a patient has been indicated for a rotator cuff repair. What can they expect on the day of surgery? 

Dr. David Hamming:
This is typically done as an outpatient, you know, they usually come in about an hour, hour and a half before the surgery and they get their IV, talk to the nursing staff, they talk to the anesthesiologist. It's a rare patient these days that we don't offer a nerve block to. And that is an injection that the anesthesiologist puts at the base of their neck to really numb up the arm for the rest of the day. I think that helps in two ways.

One is that it helps with post-operative pain. And get patients on board with their oral medicines, and transition to home more comfortably. But it also allows the anesthesiologist to give them less anesthesia. So they don't have to be quite as deep and under general anesthesia. And they, uh, they have less nausea and less side effects from the anesthetic.

Dr. Eric Chehab:
And then the procedure takes about how long?

Dr. David Hamming:
Depending upon how much other work we're doing in there. Because usually when we're doing this surgery, it's not just the rotator cuff, there's some other things that we look at in the shoulder as well. But I would say anywhere between, for the smallest tears an hour, to sometimes with the massive tears over two hours. 

Dr. Eric Chehab:
So the patients will have a post-operative experience that goes over a course of six to 12 months, let's start with the first week after surgery. 

Dr. David Hamming:
All of the patients that I do, I place in something called an ultra sling, little pillow sling where they have their arm out to the side that really helps take some of the tension off the repair. Because with your arm at your side, that's actually putting the repair on maximal stretch. And so some people think it's there for comfort or other reasons, but it's really there to help protect the repair. I let them come out of it. Uh, starting within the first couple of days after surgery to do some dangling exercises.

We would call those pendulums and I tell them, it's kind of like letting their arm rotate around like an elephant trunk. Um, they can take it off to bathe. So that's oftentimes a nice time to do it. They get the warm water running over their shoulder and they do their exercises. They work on moving their elbow and their wrists so they don't get too stiff, uh, with those joints.

But other than that, it's really just letting the biology do the work. Then you need to sleep in the sling. They need to be in public in the sling they can't drive. I really try to get them to protect it the first, at least four weeks. And personally, I will go between either four to six weeks in that sling, depending upon the size of the tear, the quality of the tissue that we're dealing with.

Dr. Eric Chehab:
And then sleep. Sleep after surgery. Yeah. And a lot of patients have difficulty. What are some tips? 

Dr. David Hamming:
And I always tell patients, this is a painful surgery. Um, and so they're going to need some assistance. They're going to use ice. They're going to use pain medications, and they're going to have to find a way to be comfortable.

As we alluded to before, for some reason, the upright position seems to be more comfortable postoperatively than trying to sleep on their back. So I usually tell people to find a recliner or get a bunch of pillows and get themselves a little comfortable nest to get in for the rest of the evening and do their best.

Dr. Eric Chehab:
I'm smiling because I used the exact same language of a nest and there's a La-Z-Boy store about half a mile from our office that people have actually rented a recliner from. So yeah, exactly the same thing. And then, you know, after that first week, which is pretty challenging, no one will ever say, gosh, I wish I could get another rotator cuff surgery, but then after six weeks we could get them out of the sling, typically four to six weeks.  And then what does the rehab look like? 

Dr. David Hamming:
It's a long rehab. Probably the two longest rehabs we have are ACL surgery and rotator cuff surgery. And, um, it's because we have to let the biology do the work at the beginning, and then we have to regain range of motion. So between that four to six week mark, and then about three months, I have them focus on range of motion and that's getting it actively and passively over their head.  Out to the side. The hardest thing they always get is behind their back, you know, getting past their hip pocket to the middle of their back. And you know, here all the time with the ladies doing their bra and other things, getting to the back of their hair, doing things behind them is certainly the slowest, but that progresses with time.

And then at three months, I usually let them start working on their strengthening. And we start easy with some bands, just light resistance. I make clear to them that they're not in the weight room. They're not building bulk. It's fine tuning, relearning how to use the shoulder. The earliest I usually let patients go back to full activity is around six months and with people's jobs and other sports and things like that, sometimes we can cheat that a little bit, as long as they're not putting too much stress through it.  But I think it really takes about six months to be able to safely do most activities 

Dr. Eric Chehab:
Yeah. That's the same number I hang the hat on and you know, I'll tell patients at six months, you'll be about 85% fully recovered and you'll make that other 15% over the course of the next six months or so to about a year.

You know, it's hard to get people fully a hundred percent back to where they were. And I use a pitcher analogy. Like if a Major League Baseball pitcher has a rotator cuff surgery, they may have thrown a hundred miles an hour beforehand, but they might throw 85 miles afterwards and you can't quite get the power. But most of us aren't Major League Baseball pitching, and we get them so close to normal that they typically don't notice a difference. 

Dr. David Hamming:
I always tell patients, my goal is 90% of normal for you. It's never going to be a hundred percent. There's going to be a little stiffness, a little weakness, maybe some occasional discomfort, but it should be definitely better than where we started.

Dr. Eric Chehab:
Yes. And that's the main thing is to realize that it is so much better than where it started, where it was weak and painful and keeping people awake at night and then they get almost complete normal shoulder function back in fact, most of the time, so close to normal that they don't notice a difference.

And then, complications, what are some of the common complications after a rotator cuff procedure? 

Dr. David Hamming:
There's certainly complications to any surgery, but rotator cuff surgery, for as painful as it is at the beginning, and as long as the rehab is, it's a pretty safe, straightforward surgery.

There's always anesthetic risks. These days I've heard anesthesia tell patients that it's more dangerous for them to drive to the surgery center in the morning than it is to actually have the anesthetic. So I think the odds are certainly with them there, but it's certainly an anxiety point for people having general anesthetic.

There's always a risk of infection. The shoulder has some specific bacteria around it that we think a little bit more about, but one of the advantages of doing these surgeries arthroscopically is that we're constantly flushing the shoulder out with water. And so we're constantly refreshing the environment we're working in and essentially self-cleaning it while we're doing it.

So thankfully the risk of infection is quite low. Most of the time I quote less than 1% and patients end up with scars. Rather than one big scar down the front, like it used to be, I usually use four or five teeny little poke holes around the shoulder that tend to fade away with time.

There's always a small risk of nerve or blood vessel injury, but again, we're working way away from those in this type of shoulder arthroscopy. So I think that the chance of that is quite low as well. But I always mentioned it. And then there's actual complications with the procedure that we're doing.

There's never a hundred percent guarantee that it will heal. And if the patient's biology doesn't cooperate, if there's a problem with stiffness afterwards, if the patient is a little too aggressive, sometimes patients honestly feel too good afterwards and they think they can do a little bit more than they should be.

There's always the chance that they could re-rupture. 

Dr. Eric Chehab:
If you do enough of these, things are bound to happen. And we do have ways to help patients with those complications. 

Dr. David Hamming:
Absolutely. We don't have to do them a whole lot, but there's always ways that we can deal with them.

Dr. Eric Chehab:
Let's go through the typical rotator cuff patient who comes in with problems with pain , strength and function, and potentially range of motion. What can that patient expect as the outcome from their surgery?

Dr. David Hamming:
The number one reason to have the surgery is to improve the pain outcome. I think that the other two things you mentioned with range of motion and strength are certainly less predictable. And so my expectation is that their pain is significantly improved. They could still have some discomfort, occasionally a little tweak.

But I tell the patients that their expectations should be significant improvement in pain. As far as how they do with their strength and the range of motion, you know, patients are not going to have a hundred percent strength afterwards. That's not a realistic expectation. But to go from not being able to raise their arm overhead, to be able to at least do some work overhead, I think that's a reasonable goal, again, about 90% of function with regards to that.

And then I think that with my experience, range of motion is a little less predictable where the shoulder has a natural tendency to tighten up a little bit, as we do the repair. There's a little scar. The tendon gets a little tighter. With the tear, you lose a little bit of the tendon so that it destroys some of the tissue itself.

And so it's a natural tendency to get a little tighter. And so getting your arm all the way behind your back, all the way to the, you know, symmetric with the left side, is probably not as reliable. 

Dr. Eric Chehab:
I don't think it can be overstated the importance of physical therapy after surgery. 

Dr. David Hamming:
I would completely agree.  Yeah. And so I never give patients the option of starting with a home program. Uh, there are certainly, uh, some trends to do more individualized home programs where they're not having to go into therapy as much. We've seen that, especially with COVID recently. But I think that learning the techniques, making sure your form is correct, making sure you're not overdoing it, but making sure that you're still being aggressive enough to see the gains we need you to make, is really best done under the guidance of physical therapy. 

Dr. Eric Chehab:
We clearly have very similar practice patterns. I agree with everything you've said. I just want to ask if you have any other insights, regarding rotator cuff repairs, rotator cuff surgery, patients undergoing these that you like to share.

Dr. David Hamming:
I think I'd like to mention one more thing that always comes up as a corollary of this discussion, and that's the biceps tendon. And this is always a challenging discussion with patients because of how, at least I have always had a challenge, conveying what's actually going on with the biceps tendon in a short amount of time, too, to help them understand. So maybe I'll take just a minute here to talk to them about that. That'd be great.

So the reason we're going to patient's shoulders, most of the time is to repair the rotator cuff as we've just been talking about, but the patients have two biceps tendon attachments, and one of them is outside the shoulder, which is always quite healthy. But the second one called the long head of the biceps runs up through the shoulder joint and it actually attaches inside the joint itself.

With the tears that we're talking about, oftentimes that biceps is intimately involved in the tear it's either destabilized and actually floating around in the tear or as we do the repair, it can alter how that biceps tendon is functioning because of how we tighten the tissues around it. And on top of that, oftentimes that tendon is not very healthy to start.

I've certainly gone into patient's shoulders before where it's either hanging by a thread or it's already gone because of the trauma that that tendon has seen throughout the years or acutely. So I never liked to leave a patient's shoulder without at least thoroughly evaluating the long head of the biceps tendon.

I think that in the past it has been, if it looks pretty good, we've just left it. But I think that patients have had some persistent pain because of the dysfunction of the biceps after the repair. And so if there's any indication, whether that tendon is being destabilized because of the tear it's going to get entrapped because of the repair or it's just not a healthy looking tendon at all, I tend to do something with that. 

And I recommend one of two things, and that's either to cut the tendon and let it go. That's called a biceps release and my personal experience, and I think the data would support that the pain relief is quite good with that. I perceived that surgery as the biggest downside is cosmetic.

I tell patients that they go flex in the mirror afterwards and they look at both arms, one might look a little bit more like Popeye than the other side, but functionally, they should still be able to turn a wrench. They should still be able to do 90 plus percent of their activities with no restrictions. They might feel a little crampy at the beginning, but overall, they should not notice any difference in their arm function. 

The second option though is to reattach it. And that's called the biceps, tenodesis, and there's lots of different ways that you can reattach it, which I don't think we need to get into here.  But the main reason for that in my opinion is cosmetic. You can have an argument about whether there's subtle differences in some of the functional tests that we do. I'm always worried about whether at the reattachment site or still pulling through the tendon there that we could cause some more discomfort down the line.

So I always have an individualized discussion with the patient about those risks and benefits for them particularly, but I'd say in general, the outcomes in my hands are a little bit more favorable with releasing it. 

Dr. Eric Chehab:
Well, we really do have similar practice patterns. I totally agree. And when I talk to patients about biceps release versus biceps tenodesis, where we're anchoring in the bone, I'll sometimes just use Brett Favre or John Elway's example, these guys whose long head biceps, either tore, spontaneously, or had them surgically cut, who then won a couple of Super Bowls afterwards.  And so I think it gives people an idea of just how well you can function with the release of a biceps. 

Dr. David Hamming:
Right. It was really easy in Denver to get to sell that one. Because John Elway is an idol out there and they said, ‘Oh, I'm getting the John Elway treatment? I'm in!’

Dr. Eric Chehab:
Well, listen, I think we've covered a lot of ground here with the rotator cuff, which is not easy to do.

I think the big points being number one, every rotator cuff tear has its own personality, I guess. And every patient who has a rotator cuff tear needs individualized evaluation, individualized treatment plans. You know, you hear an awful lot about people talking about their friend who had a rotator cuff injury, and it really could be along any line of the spectrum. And I try to tell people not to gauge their expectations based on someone else's experience because it's so individual.

Dr. David Hamming:
Completely agree. 

Dr. Eric Chehab:
David Hamming, thank you so much for being here with OrthoInform. We really appreciate your taking the time. If our listeners would like to learn more about Dr. Hamming and his practice, please visit ibji.com. Again, we really appreciate your time. Thanks for being here. 

Dr. David Hamming:
Thanks so much, Eric. It was my pleasure.