Featured Speaker:

Ryan Urcheck, M.D.

Ryan Urchek, M.D., is a fellowship-trained orthopedic surgeon specializing in shoulder, knee, elbow, sports medicine and arthroscopic surgery. His interests include rotator cuff tears, shoulder impingement, labral tears, ACL joint pain, cartilage injuries and ligament injuries. Dr. Urchek completed his undergraduate studies and medical degree at The Ohio State University. He completed an orthopedic surgery residency at Summa Health and pursued fellowship training in sports medicine at Emory University, where he cared for athletes at Georgia Tech and worked with the Atlanta Falcons. In his free time, Dr. Urchek enjoys spending time with his wife and three children, barbecuing and Cleveland sports.

Transcription:

 Scott Webb (Host): Overuse and traumatic falls are often the cause of rotator cuff injuries, and though surgery is sometimes needed, many patients will heal with physical therapy and time. And joining me today to discuss rotator cuff injuries and the various treatment options is Dr. Ryan Urchek. He's an Orthopedic Surgeon with Summa Health.
 This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Doctor, it's nice to meet you. Nice to have you here. Coincidentally, I was just at the orthopedic doc yesterday with our daughter, uh, who does have a bit of a rotator cuff injury. Fortunately, no surgery indicated, just need some PT. But, you know, for everybody else who wasn't just at the doctor's office yesterday, uh, what is the rotator cuff? Where is it located and what's its role in the body?

Ryan Urchek, M.D.: So the rotator cuff is a group of four muscles and tendons that come off the shoulder blade and connect the shoulder blade to the shoulder bone itself. They basically stabilize the shoulder so then your other bigger muscles, like your deltoid, can do its job. So, it helps with stability and there is some strength involved, but there are these really small muscles kind of deep inside the body that are common to injury, sometimes trauma and sometimes more commonly from overuse.

Host: Yeah, that was the case with our daughter, now that we've had the MRI, we know it's the rotator cuff, not torn, so it was good news overall, but for some folks, though, if they actually tear their rotator cuff, like, what's involved there, and what's the leading cause of a tear?

Ryan Urchek, M.D.: So the leading cause of the tear would be kind of like your daughter. It's actually usually more overuse or in older patients, degenerative. So it's very common in patients in their 50s or 60s to actually get small tears that happen over time. Thankfully, they are small, so they will be treated typically like your daughter with physical therapy and time.
So more commonly, that's the nature of the tears, but just as important, you will have younger patients in their 30s, 40s, 50s, or sometimes older, and they have a trauma. They fall, they're doing some gardening, and the most common way would be landing on an outstretched arm. So you kind of break the fall with your arm. You put your hand out, which is just natural. And then the rotator cuff can take the brunt of it. And then if it tears that tendon off the bone, now we're into a scenario where, you know, we're having pain, weakness and need further workup.

Host: Yeah, and I'm assuming, you know, whether it's overuse or some sort of trauma, and I do hear that a lot, you know, the sort of gardening war stories, the gardening traumas, so I try to take it easy when I'm out there because I don't want to fall, but regardless, when we talk about the symptoms of a rotator cuff injury, what do folks generally feel?

Ryan Urchek, M.D.: The most common, uh, symptom would be pain, and it's along your deltoid or the lateral shoulder. So, patients commonly don't point, like, directly to where you would imagine the shoulder joint is. They usually rub the outside of their arm, kind of between the top of the shoulder blade, and down to their elbow, and just kind of do this motion.
It just hurts there, and then my spidey sense is already up that that's, uh, what's going on. Some sort of rotator cuff problem. Specifically night pain, is the predominant symptom that patients come see me. They can usually deal with pain with their job or activities. They take some medications, kind of get over it, but when patients stop getting good sleep at night, that's when they come see me or their significant other says, hey, you're keeping me up at night. You got to go see somebody about it. 

Host: Right

Ryan Urchek, M.D.: Pain, specifically at night is a leading symptom, but if it's an acute tear or a large tear, weakness can now become more of an issue where patients, especially like away from their body with their hand or above head, they start feeling like they can't even raise their arm up to, you know, ask a question or whatever may be above head, putting dishes away. That would be a symptom of a rotator cuff problem.

Host: So, you know, in my experience, the rotator cuff, at least with our daughter, it didn't just heal on its own, right? It feels better and it doesn't hurt as much, but I bet if she tried to go out and throw a softball right now, it would hurt. So generally speaking though, does the rotator cuff heal on its own?
And when should someone see a specialist? Like if, it's a 16 year old, and they're going to continue to want to play sports, they probably need to come see you. But in general, if it's an older patient who doesn't need it to throw softballs across the diamond, you know, do they need to come see you?

Ryan Urchek, M.D.: So thankfully most patients can heal their rotator cuff problem on their own. And I use the word problem because if it's more inflammation, you know, you hear tendonitis, bursitis, which thankfully that's the kind of majority of patients, those do heal. Maybe not necessarily on their own. They usually do if you give them enough time, but certainly we can speed it along with anti inflammatories, physical therapy, or even like a cortisone injection because we're trying to reduce the inflammation, but at the same time strengthen all of those small little muscles and tendons with specific physical therapy that we don't always do.
We're pretty good at hitting the large muscles, the lats, the pec, the deltoid, but these little rotator cuff muscles kind of need these smaller little specific exercises that we don't always learn and therapy has to help us. So, I think the majority of patients fall in that category, but you know, if you start talking about your traumatic tear, where again, you have your 45 year old kind of being brave, getting up on a ladder, falls off and now they can't raise their arm up above their head and they have a acute traumatic tear where the tendon came off the bone; unfortunately, we found that those don't really reconnect to the bone. So it kind of depends on the size of the tear in the patient. I'm not trying to say they all need surgery, but those are the ones where you know, a lot of times we may have to really consider surgery to fix that tendon back to the bone to give that patient their ultimate function and pain free life back.

Host: Yeah. And I wanted to talk a little bit more about diagnosis. Wondering how do you diagnose? And then let's talk about treatment. Is it, do you always go, you know, especially if it's not a massive tear, do you go PT and injections, that kind of thing first and surgery's a last resort?

Ryan Urchek, M.D.: For diagnosis, it kind of goes back to starting with a good, you know, physical exam and history of the patient. And that kind of goes back to what we were talking previously. Hey, is this something that just came up with some gardening? You know, maybe they still have 90 percent of their function only hurts them at night.
I mean, those patients, usually we will start with the easier stuff. Now, if a patient comes in for diagnosis and again, they fell, they had a baseball injury, like your daughter or something where, you know, they dislocated their shoulder, certainly we're getting x-rays to rule out any fractures. If it's an older patient, we'll get x-rays to rule out arthritis because arthritis can look a lot like rotator cuff issues. And we want to see that. So we will. We will get x-rays to start and then depending on the patient, we might get that MRI you're talking about. Again, if it's somebody who fell, can't raise their arm, and we have a high suspicion for a rotator cuff tear that we don't want to miss, we will you know, get MRIs kind of quicker. If it's that patient, like you said, it's kind of the weekend warrior, their pain is not terrible and we haven't tried... 

Host: A pickleballer maybe, you know, pickleball is so popular. Yeah.

Ryan Urchek, M.D.: That's exactly. So, you know, we'll try the easy stuff first, you know, for maybe a month or two, therapy and injections, because again, the majority of those patients will get better. But if they don't, that's when we will start to go down the road of MRIs. And then again, that goes back to the treatment as well. The vast majority of patients that I see, just saw a patient this morning. You know, again, they certainly are having pain and it affected, and that's why they're coming to see me, but it's not like, Oh my gosh, I have to have surgery tomorrow.

They can still function. They can still work. It's just, again, the night pain starting to up on them. So a lot of times we're starting with those anti inflammatories, physical therapy, maybe a cortisone injection if it's bad enough or been lingering, trying to reduce the inflammation, allow those muscles to get stronger, and the majority of them get better.
 If they go down that road and they have a small tear, maybe we start to bring up the surgical option, or again, in that acute patient, they took a fall, they can't raise their arm up, we get an MRI maybe on the sooner side of things, and two out of the four tendons are torn in the rotator cuff and, you know, they're a labor intensive patient.

They got to be able to raise their arm up. Well, they have a high likelihood they may not be able to get back to that without surgery. So we have to maybe talk about the surgical option a little sooner than anybody wants.

Host: Yeah. Yeah. Wondering about the recovery process. I'm sure there's a range, as you said, you know, for some folks, this is going to heal on its own. Others it will heal through physical therapy. And then of course we talk in surgery as a last resort, perhaps for most. So what's the sort of broadly speaking, the recovery process like?

Ryan Urchek, M.D.: Sure. And when I start talking about the surgery recovery process, I think a lot of patients will start to say, okay, that's why we want to try to avoid surgery if possible, because a lot of times I'll have patients come in and they say, Yep, I already talked to my buddy. He went through rotator cuff surgery and he was like, Oh gosh, well, if you have to have it, you have to have it, but you know, it's going to be a road to recovery.

So we've done some literature and even if you have a small tear of the rotator cuff as we get older, we've shown that physical therapy, maybe an injection and giving it time, is pretty successful treatment for getting patients back to where they want, and those studies have actually found that those patients usually figure it out within two to three months if they're going to heal themselves and feel better.

So, it's not like we have to give it six months or a year, although, you know, you can do that if the patient's just really trying to avoid surgery. But even in two or three months of some good treatment and you're increasing your activities, lots of times patients will kind of figure out, hey, this is working for me and I'm happy.

Or nope, this is not working. And, we got to talk about surgery and studies can be all over the place, but usually about three fourths of patients in that specific scenario where, you know, you do have a small tear of the rotator cuff, a little bit older. They're pretty successful with no surgery, but maybe, again, a quarter of them might still need surgery.

So then, furthermore, if you're talking about the surgery recovery for a true rotator cuff tear, where we are repairing the tendon to the bone, that's a lengthy recovery and pretty slow overall. In general, depending on the tendon tear, you're talking about six weeks in a sling afterwards, starting physical therapy within the first couple weeks to a month to get the shoulder moving, usually three months down the road, you're doing some light strengthening and then, you know, the minimum healing time before I let patients typically swing a golf club fully or really higher level activities is about six months down the road now.

Again, we're letting patients do more and more and obviously it depends on the size of the tear and the you know, 

Host: Yeah. 

Ryan Urchek, M.D.: the patient scenario if they have any risk factors for not healing, like diabetes or smoking or things like that. But there's also pretty good evidence after surgery that patients will feel better and continue to heal for 10 months after surgery. So all in all, I'll tell patients after surgery, you're looking at about a 6 to 12 month recovery, depending on your goals and how you heal.

Host: Yeah. Wondering, I would love to believe as a kid who grew up in the seventies and watched the Bionic Man, you know, I'd love to believe that, well, once that shoulder is repaired, if we have to do surgery and it's repaired, well then it could never be injured again. But I don't know that that's true, which is great to have experts here, but just wondering on a repaired shoulder, you know, one that was pretty well devastated, are you more likely to get injured again on that particular shoulder, the repaired shoulder?

Ryan Urchek, M.D.: Not necessarily likely to get more injured again or torn again, but certainly overall after you're all healed up and even if you're feeling good, it's not uncommon for patients to say, Hey, this is like 90 percent of my other side. You know, certainly we're shooting for, Hey, this is like, you've never had surgery before, but I think the more common scenario is patients say, Hey, this is way better than it was before surgery.

I can sleep at night. I can do my function, but it is not uncommon for patients to say, yep, if I garden too much, or if I shovel the snow, you know what, my rotator cuff side is a little bit more sore than my left side, even years down the road, and we've actually done those studies as well that shows, over time, you know, results can deteriorate a little bit over the course of 5, 10, 15 years, so even when I have that patient in my office and let's say at 10 months after surgery, they're like, Doc, I'm 100 percent or I'm 95%, I feel really good. I actually still encourage those patients to do that physical therapy or those little exercises we were talking about, maybe even for the rest of their life, maybe a couple times a week or, you know, like, say for your daughter, every time she's going to play softball or basketball, it's probably a good idea for her to warm up her shoulder and get it going because if she had a three game, tournament over the course of a weekend and she wasn't doing her exercises even two years from now, I wouldn't be surprised if she said, you know what, I need some Aleve or ibuprofen. I flared up my shoulder. So I guess, you know, I think you're a little bit more prone to just some symptoms or flaring up, but thankfully not necessarily, requiring more surgery definitively.

Host: Yeah. Not necessarily tearing it off the bone again, like you did maybe the first time. I just want to finish up here and ask you, is there any way to prevent rotator cuff injuries? I understand, obviously, like, don't fall off the ladder. Right. Yeah, sure, that's great advice for everybody. But in general, especially when we talk about the overuse injury or overuse type of injury, is there anything that people can do to prevent those injuries?

Ryan Urchek, M.D.: Of course, I think it's like we were talking about just kind of staying ahead of it. So unfortunately, some patients are just prone to shoulder issues. If you are one of those patients that your shoulder can flare up on you especially with the overuse, well then I think, you know, getting in and figuring out a good home exercise program you don't necessarily have to go to the therapist every other month for the rest of your life, but if you can, have the bands or light weights and know these rotator cuff exercises; maybe before every time you golf, you do five to ten minutes or during golfing season, you know, maybe three times a week. You're just kind of staying ahead of it and keeping that rotator cuff nice and warmed up and strong. That typically will prevent needing the patient popping Aleve or ibuprofen after every round of golf or every time gardening.
So it's kind of, you know, staying on top of it, if you're that kind of patient. Some patients are luckier than others. They don't have shoulder issues, but they have back issues or neck issues. So, so, you know, 

Host: And every other type of thing issues. Yeah.

Ryan Urchek, M.D.: Exactly. So if you just know you, you're one to be prone to that inflammation, then Aleve ibuprofen, if it's safe for you, and then, you know, those home exercises, staying ahead of it's probably the best thing you can do to prevent those recurrences or pain coming back over and over again.

Host: Well, I'm definitely going to give that advice to our daughter to warm that shoulder up before softball. And that's really what it was. It was just a lot of games in a short period of time with a lot of extra practices and swings and all of that. And I'm sure for other people, you know, suffering the overuse type of injuries is a similar story. So I appreciate your time and your expertise today. Thanks so much.

Ryan Urchek, M.D.: Thank you for having me. I appreciate it. 

Host: And for more information, go to summahealth.org/orthopedic. And if you enjoyed this episode of Healthy Vitals, we'd love it if you'd leave us a review. Your review helps others find our educational content. I'm Scott Webb. Thanks for listening, and we'll talk again next time.