Cuff: An Overview
Guest: Dr. David Geier – Orthopedic Surgery
Host: Dr. Linda Austin – Psychiatrist
Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. David Geier, who is
Director of MUSC Sports Medicine Clinic.
Dr. Geier, rotator cuff injuries are so common. Just what is the rotator cuff?
David Geier: The rotator cuff is a
series of tendons. These are the
muscles, if you look at someone from behind, that come off the shoulder
blade. As they head towards the
shoulder, the ball and socket part of the shoulder, they form tendons which run
under the bony tip of your shoulder blade.
The tendons run under there and attach to the ball of the ball and
socket joint. And these are the muscles
and tendons that help stabilize your shoulder while your arm is in overhead
positions and doing work out away from your body and behind your back. They stabilize the shoulder and, as such,
they’re in positions to very likely suffer from overuse injuries.
Linda Austin: What are some very common
ways that people injure their rotator cuff?
David Geier: Well, it’s
interesting. Rotator cuff injuries can
happen in athletes and in people involved in recreational sports, such as
people that play overhead or overhand sports, such as tennis or golf, that
require a lot of work with their arm overhead.
But it can also be in just your everyday adult. It’s not uncommon to get rotator cuff
irritation or even complete tears from simple things, such as a weekend of
gardening or a weekend of painting, where they’re doing a lot of overhead
activity over a short period of time.
Linda Austin: So, in other words, can it
be an overuse problem, not a severe movement, just using it over and over
David Geier: Absolutely, not at all
uncommon, probably more common to be an overuse injury. It certainly can happen traumatically, in
injuries that cause shoulder dislocation, but much more common with overuse. And it, actually, is not at all uncommon for
the person to not remember the inciting event at all. They just start noticing pain several days
after, maybe painting a room over a weekend, or something like that. They don’t remember doing anything at all.
Linda Austin: Is that the same as a
Linda Austin: It’s not exactly the same
thing, but they’re often interrelated. A
frozen shoulder is where the capsule, the lining of the shoulder joint, starts
to scar down and constrict and kind of limits the motion of the shoulder in
every direction. Now, that can happen
just on its own for kind of unknown reasons, but more commonly occurs with
underlying injuries, the most common of which is a rotator cuff tear. So, a rotator cuff injury can cause weakness
and pain related to actual tendons being torn.
But the limitation of motion that sometimes follows that is often a
frozen shoulder that’s related to an underlying rotator cuff tear.
Linda Austin: When somebody comes in to
see you with a shoulder problem, how do you diagnose that? How do you work it up?
Linda Austin: Well, I think you start by
trying to figure out if they did have a traumatic or acute injury. Or, is this an overuse injury, or do they
remember doing anything at all? So, you
ask questions like, does it hurt reaching overhead? Does it hurt holding something out away from
their body? Does it hurt reaching behind
their back? And then in your younger
patients, it may be that you’re worried more about dislocation, like
instability or a labral tear. Does it
feel like it pops out of place, or do you get popping in within your
shoulder? So, I think a lot can be
answered just by asking questions. And
then I think there are some physical examination tests that clue you in one way
or another. Efforts to reproduce the
patient’s pain and certain tests causing certain discomforts lead you in. And then I think it gets into radiologic tests,
plain x-rays, and potentially even an MRI if you suspect something such as a
rotator cuff tear.
Linda Austin: How do you treat it?
David Geier: It really depends on the
level of injury. It’s not at all
uncommon to have what we call impingement or irritation of the rotator cuff
that’s essentially an overuse phenomenon.
And most of the time, that’s very easily corrected with aggressive
physical therapy to strengthen the other muscles of the shoulder and work on
proper shoulder mechanics throughout activities. That, most of the time, can get better. The question arises when you get to the
partial or complete rotator cuff tears.
There, you’re starting to head down a path that, despite physical
therapy, despite, say, cortisone injections and other nonsurgical means, it’s
much more likely to head to surgical treatment.
the surgical treatment for rotator cuff tears has advanced tremendously over
the last 5 to 10 years to where most rotator cuff tears can be repaired
arthroscopically, through 3 or 4 little stab incisions along the shoulder. Through very small incisions, small suture
anchors can be placed to repair the tendon back to bone. But the advantage of the arthroscopic repair
is much quicker rehab in terms of regaining range of motion, much less pain
related to a big incision. So, we’ve had
much improved outcomes through these newer technologies.
Linda Austin: I’ve had frozen
shoulders. They can be unbelievably
painful. You make the PT sound kind of
easy. I thought it was really hard. Why is it that that is so painful?
David Geier: I think it’s a combination
of factors. With a frozen shoulder, you
get that scarring of the capsule, and you almost have to break up that scar
tissue. So, physical therapy is really
pushing you much further than your frozen shoulder really wants you to allow. And that gets to a concept, you know,
physical therapy for these rotator cuff tears, it is uncomfortable but it’s one
of those things, they can push you harder than you can push yourself. And, a lot of times the patient needs that to
get through that limitation of motion or to get stronger than they could get on
yes, a lot of times, it’s very uncomfortable.
And there are some things we can do to make it a little less
uncomfortable, such as cortisone shots.
But, really, the therapist, albeit they’re causing a fair amount of
pain, they really have the shoulder and the patient’s best in mind.
Linda Austin: Your calling it
uncomfortable reminds me of the obstetrician saying that labor pains will cause
a little bit of discomfort.
David Geier: Yeah.
Linda Austin: And, of course, the thing
you most want to do with those shoulder injuries, or frozen shoulder, is to not
move it at all, but that can be the worst thing, right?
David Geier: Than can, absolutely. That is thought to be one of the ways that it
actually kind of happens. Your shoulder
hurts for whatever reason, the acute injury or the overuse injury that may have
caused a rotator cuff tear, or a milder version of that. But it feels comfortable to put it in a sling
or even just lay it by your side and try not to use it. But, by not using it, your capsule can kind
of scar down in that position and then it becomes more painful to use it. It becomes kind of a downward cycle. It gets stiffer. It gets more painful, and you really to break
through that. And, unfortunately, I
think that’s the reason therapy is so uncomfortable. If even therapy doesn’t work, then you’re
talking about, potentially, surgery, which sounds somewhat barbaric, taking
somebody to the operating room and putting them to sleep and then the surgeon,
physically, just pushing very hard on the shoulder to break up all that scar
tissue. So, therapy is a milder version
of that but, no question, very uncomfortable.
Linda Austin: Well, at the risk of
sounding like a major hypochondriac, why is it that shoulder injuries hurt the
most in the middle of the night?
David Geier: That’s a good question that
we don’t have an answer for. But, when
you hear that it hurts in the middle of the night, it doesn’t surprise any of
us. I think it’s related to certain
positions that people like to sleep in.
And a frozen shoulder or rotator cuff doesn’t allow the shoulder to get
into that comfortable position. So, even
if the patient is asleep, a turn a certain way elicits a pain that, in a
conscious person, they can avoid that position and not have that pain. It’s very common to have night pain with
shoulder pathology. And one of the
things we fight as physicians is coming up with ways to get through that. Therapy is somewhat effective. Sometimes cortisone shots are effective. But, at the end of the day, sometimes that
night pain is really the worst part of it.
Linda Austin: Dr. Geier, thank you very
David Geier: Well, thanks.
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