Dr. Mighell Lecture, How I Mobilize the Cuff Before Repair

We’re going to talk about here as you will see patients that have rotator cuff problems in your practice. And by far most people who have rotator cuff tears will never need surgery. OK so. If you’re well so young it doesn’t matter. But if you’re 60 years old, I’m close to 60. I have a 50 percent chance of having a rotator cuff tear the age of 60. We don’t operate on every six-year-old. So people who have rotator cuff tears always come in and they’re like I was a Mason you know, I was a brick layer, I was a hairstylist I was doing hair everyone always wants to think of a reason why they have a rotator cuff tear. But the majority of them are just degenerative. They just happen. So people get rotator cuff tears but the patients always will go well I was in college I was playing football and I hurt they didn’t tear the rotator cuff when they’re in college you don’t live like 40 years with the rotator cuff tear. In college people don’t usually tear the rotator cuff so it’s very unusual to see someone in their 20s with a rotator cuff tear. I don’t think he’s been with me now close to five months. We haven’t seen one 20-year-old with a rotator cuff there. They don’t get it. They may get rotator cuff tendinitis and may have a rotator cuff partial tear which is a bad term deal because when patients read their report they go doctor while I have a rotator cuff there and says partial tear of the rotator cuff and what is a partial tear of the rotator cuff.
In your opinion as a radiologist. It’s almost like it’s scuffed.
If I took something rubbed this tablecloth and it was all rough but that’s what a partial tears are. If It’s on the underside it gets beat up a little bit but it just means the actual thickness of the cuff is less. Not that it’s like my skin. I hate to say it but like I used to have nicer skin. But you know your skin gets thinner as we get older. We all hate it. You guys not to worry about it yet. But you know that’s it’s thinner and the rotator cuff you get thinner and that can be a partial tear when you see thinning of the cuff. So that’s a bad term because patients just read cuff tear all they see in the report and they’ll come in. I got six tears and my cuff Doc and I’m like All right six tears here cuff and they’re reading the report or labral tears.
So what percentage of the population at age 40 has a labral tear. If you had to say Neal? 50 percent. That’s just part of the natural aging process. But patients get their MRIs back and they go Oh my God I got a labral tear or if they get in a car accident God forbid then someone’s responsible for that labral tear. It’s not right. So you know and that’s a tough one because he knows right now my daughter pulled out in front of another car in rural Virginia and she stopped and they hit her bumper. But now there’s injuries everywhere. Like a 20 mile an hour collision injury you know anyhow. So I want to start with that because most people don’t need to have surgery for rotator cuff problems. So then the question is who does. So there is one variant that usually is more likely to get it.
So if I fall, God forbid, again like I do with my Achilles going out of this restaurant. Land on my arm and I tear my rotator cuff and acute traumatic tear which is one out of six. Those are patients that benefit from rotator cuff repair more than others because they did not have a problem they had a fall. And if so what I wanted to show you is that what kind of goes into if you do have surgery. So we know that if you if you don’t have an acute traumatic tear and you have a patient that’s over the age of 65 you always should send a physical therapy first. You know they’re going to benefit from some physical therapy and if you do injections you can inject them. But those patients will probably benefit from one round of physical therapy. They always want to get an MRI.
I know they probably come to you guys and go I need an MRI because they see that on TV and that’s OK to get an MRI. But just remember when they get that MRI. The MRI for me right now says partial thickness rotator cuff tear, labral tear, biceps tendonitis and tendinopathy because I’ve had an MRI my shoulder doesn’t hurt right now but I’ve had it injected before. So just make sure you I usually explain them I said Look I’m gonna get an MRI but you’re sixty five we’re probably going to see a partial thickness tear in some tendinopathy. So when they come back. Oh hey doc, exactly like you said I had had this. And you can treat him therapy and injection anti-inflammatory is all, that is just fine. There’s no urgency in treating degenerative rotator cuff tears. Meaning that if you fall outside the door that’s urgency.
But if it’s. I was working out at the gym and my shoulder hurt or I was you know kind of doing some gardening and my shoulder hurt. Well there’s not an urgency to really getting you know an MRI or surgery. So now let’s go flashback to the patients who do need to have surgery and I’ll see if this kind of can advance a little bit. So this is actually how clear and this is what it really looks like. If you have everything working well this right here is the bone. This is what a rotator cuff tendon looks like. You don’t tear the muscle you tear the tendon. So this tendon should be on this lunar landscape. It should be attached there but it’s not. So I just have a little grasp for where I’m to pull the tendon back. But if you get an acute tear usually it’s really easy to bring it back.
So if I go in and someone had a tear for a year it can be scarred and it can be hard but if I go in with this what we call you know a kingfisher or a bird beak grasping. Grab it and pull it and it comes right over I know that was a relatively acute event. So what I want to do to look at these is I have to do surgery. So everybody always wants to know what is it like to have surgery. And let me tell you something like people are. Not surgery adverse in the United States. I mean we do people go to us to have surgery for all kinds of things and you know that there’s cosmetic surgeries there’s different surgeries or dental surgeries. But I think its still surgery. And so one of the things that we worry about. Is that OK. This is how you have this.
This is what I see when I do a surgery but I have everybody now going to get like benzoyl peroxide wash because we have a dermatologist in the back. But what do men have? Men are dirty. My daughter loves when I say this. We have we have P acnes or QT but 10 times the amount of bacteria on the skin of the male than female. So if you swab a man’s skin it’s much greater. So I have most of my patients go get this wash the night before surgery to decrease the load of bacteria and then we also prep it out obviously before surgery and we give antibiotics I.V. and everybody said everybody gets I.V. Antibiotics 20 minutes we like before surgery but within an hour we generally want it into the system. So that’s really important when you’re doing surgeries. The other thing is that what you guys help me with is it what’s a good surgical candidate.
Well you know you don’t have diabetes. I’m making that assumption but I’m so you don’t have diabetes you’re not a smoker that’s a good surgical candidate. You know this lady enjoys smoking cigars and you know she stays out late but I mean the point being is that you have to look at the patients you’re selecting so rotator cuff healing is predicated upon. Not being a diabetic. Not having immunal compromise. Not taking steroids. Not smoking. So if I have a patient who has all these problems sometimes I steer them towards non operative management because the chance of the tendon healing goes down. So we know that the tendon healing is best in younger patients. So an 85 year old has a rotator cuff tear. Yes you can do surgery but the chance of that tendon healing diminishes dramatically. So that’s a patient better off with non-surgical management.
And if I do this procedure the minute you fix a rotator cuff you’ve just taken away six months of somebody’s life. So when I’m 80 years old my might not have that much more time right. I don’t want to lose six months maybe I want a shot and go back to the golf course or go play tennis or travel. So you have to think about the people don’t think about their recovery that well you know they’re like I’m to go get this fixed. But even for me in this this is basically two months of being in a boot. And luckily Earl’s here for another six, But no I mean it is hard. So when you think about this sometimes you go Yeah I got to get this fixed but you don’t think about the aftercare that goes into it or the amount of time that you’re gonna put into something.
So I like to use this portal so what were the thing that’s gotten better and that’s what I’m a guy who likes like kind of clever things, like you know whether it’s new apps or new phones or new computers or robotic assistants. But basically we have these fiber optics that I can look at when I take a picture of the suture. It looks as large as a rope. I mean the fiber optic cameras we have today are just unbelievable. And the water pumps we have in the shavers and the devices we have to do surgery is really fantastic. But I’m sorry when we’re looking at these. It’s like puzzling. So I don’t know if anyone like puzzles here but you’ve got to kind of go in the shoulder and once you get the burst out of the way and you’re looking at the tendon you kind of have to determine there’s like three different types.
So this is the most common type that I see as more of a crescent type tear with this. Usually you can just bring it back and it’s easy like this is a nice one. It’s like right on the edge it lays down nice you know where you have to fix it but what you’re trying to do is get to get a tendon to heal you need the bone to bleed. You need the tendon to basically scar to the bone. It’s not like you grow the tendon back into the bone. We have a dermatologist, we’ve disturbed Sharpey’s fibers. I don’t even know what you call that fibrous tissue that now but it’s not really tendon is it. So what it comes back when it heals isn’t really the same as a tenant you had when you were born but for that to occur requires strict immobilization really good compression of the tendon against the bone. And the reason for that is in our joint and the shoulder joint has fluid and the fluid will degrade any scar. So your shoulder fluid keeps the joint limber but it’s a disaster for what I’m trying to do because if you have motion in the fluid gets between there the lice the signs and the other enzymes will degrade my little clot.
Now my tendon doesn’t heal so I want that compression. So that’s very important for healing. So nutrition becomes really important too. So you know you can’t say enough about nutrition but if people don’t eat healthy and don’t get enough protein and the rest of the minerals in their diet they’re not going to heal. This is when it gets really fun. So this is a tear pattern called a U shape tear but we fix it almost like you’re fixing a football. So you have this big you and what you do is you minimize the amount of surface area by passing these sutures once you tie all these. Now you’ve made a crescent suture so the whole idea is to kind of get back to the crest and suture again and repair that. And so you can do that. That’s a u-shaped tear. And finally, this is of trickiest one because it’s hard to find the tip.
So this makes it look real nice in a cartoon but usually there’s part of the tendon goes posterior or back and you’ve got to grab it and pull it back. So we have all these amazing little instruments to look like alligator graspers that can grab that tissue and pull it back. And what we’re trying to do is so the tendon back to the bone and before I do this, I take a burr and I burn down the bone. So I make it bleed. So once we’ve done that we go oh we’re going to mobilize the tendon, but this is actually what surgery looks like. It’s not like doing open surgery where you think there’s lots of bleeding and other things. What you’re doing with these little probes that are heat probes is you remove all the scar tissue. So one of the goals is whenever you have an injury you get a lot of scar tissue. If you can remove all that scar tissue you can mobilize the tissue to bring it back.
And then you’re going to release and remove. So this is actually what a ball looks like. That’s a human ball. And this is a really nice one. So this articular cartilage is pristine. So what. And here’s something also to take to the bank. You can see that the socket also looks good. If you have arthritis in your shoulder. So let’s say you and your practice have a patient with arthritis. We would never fix the rotator cuff in a patient who has arthritis. So once you get arthritis that’s like having a queen and an ace and blackjack you know. That supersedes any rotator cuff problem. So as soon as we see arthritis or if you see it on the X-ray or the report from Dr. Prakash says mild to moderate glenohumeral arthritis I would never fix a rotator cuff in that patient. That patient is going to need a shoulder replacement someday if they need an operation and they don’t have to have a shoulder replacement.
I mean you can try some of the homeopathic things I mean. I mean it’s funny because my best friend’s homeopathic doctor and both of his sisters are. So they use stuff like arnica and tumeric and all these different things. But that’s not bad. You know if you can get someone to take that to hydrate new exercises you can avoid you know some of the problems with arthritis or at least put off having a joint replacement for a while longer because once you replace your joint. You’ve just started the clock. Because that joint will fail. It will predictably fail and all human beings. So I like not to do a joint replacement until you reach that kind of point where the patient can’t sleep they’re miserable they’re bad days outnumber their good days. But you would never fix a rotator cuff tear and a patient with arthritis. And I get a lot of patients that come in who have their MRI report and they read rotator cuff tear but they don’t see the part that said severe arthritis.
So I thought this is actually what it really looks like and I thought this was a really cool picture because sometimes I can actually cut between the tissue and I can pull this tissue back down. But if you do this the more kind of difficult the operation the more likely it’s not going to heal right. The simple tears heal 90 percent of the time. So if you have a small simple terrible heal very well the bigger the tear it can be very difficult to slide this where I’m shown the interval slide but this is actually you know when we have these cameras a resolution is unbelievable and this is just kind of and we’re identifying the tear pattern. We have these tools that grab it. We can pass the sutures with this. So once I grab the tissue in the inside I can put stitches into the shoulder so you can see from the fiber optic camera the shoulder glows.
So it has this kind of look to it so we can kind of you know do this operation in a very timely fashion but I think the thing that is most important isn’t doing the operation I think. I mean we saw probably 10 people that had the surgery date to this point I’ve done two thousand rotator cuff repairs. But more important than the actual surgery is patient compliance because when I give you a n immobilizer and send your home. I don’t know what happens. You know if I tell you not to use your arm because people will try to do more. And so you really have to impress upon people that if you don’t hold this still and you start moving this too soon you know these sutures that we use will actually come apart and then the tendon won’t heal. And so probably the biggest disastrous for me are people falling after surgery because just like I have this boot on if your arms in a sling your balance isn’t as good.
So when you’re trying to walk right I always get. So I’ve had one guy fall in his pool because he was trying to clean this pool with his immobilizer. I had a guy fall off a floating dock. I’ve had someone slip. At the DMV because they wanted their handicapped permit so they fell again at the DMV. So you know or they take too much pain medicine. So I think that’s a real problem. But we’ve kind of the new law was good. I mean at least in my practice because I don’t give hardly any Percocet, I’ve written one Percocet scripts in the past two months. You know I don’t give that out anymore. And I mean I don’t know about you guys in your family practice or internal medicine practices if you went back five years whether you’re giving out more pain medicine but even for fractures we try not to do it.
You know we’ll give out tramadol or anti-inflammatory. And you know it became a big problem and was a big problem my practice because then the patients come back just to get pain medicine or the mother that was sorry. I’m starting to pick on mothers but the mother that goes Yeah my son still hurting. He needs some more Percocet you know. And I’m like looking at the kid like he’s not hurting you know. But the moms like sitting there and so you guys are probably a better psychiatrist than I am but I can figure that one out. You know I could figure that out. So I don’t know. So I don’t know if you guys had any questions about rotator cuff tears that I can answer perhaps. And certainly, if you have questions during the dinner you can come and we can talk a little bit.
But this was more just a way of us saying thank you know and just for me to get to know when I see your name, I can put a face to a name and I know where the patient’s going. And also just like I was telling Dr. No I’ve gotten my my painter and my air conditioner repairman as a patient when I get hurt. Now I got to find a doctor so I got to know who’s out there so. But Dr. Prakash reads a lot of my MRIs and does a lot of favors for me because one of the things about I’ve been the team doctor at plant high school for about what maybe twelve years now ten to twelve but the tower radiology has graciously given us up to 10 MRIs for free every year because interestingly everyone thinks Plant’s like such a wealthy school.
But most my football players a lot of them are either on Medicaid or have no insurance you know or there is five thousand dollars to get an MRI or something. I mean these are these high deductible plans and you know a kid who’s from a working mom can’t afford that. So they’ve been great and then they’ll read the MRI and coach Wiener wants to report by. He thinks we’re a professional football team so the injury happens on Friday night. he’s Like Doc. Hey what the MRI say. Like he’s asking me Saturday morning. So he’s been really good about helping me out with stuff like that. But I mean we have like it with our group just not shoulder. But we do all facets of orthopedics so I mean and that’s what I think is kind of unique as we’ve kind of sequestered out different areas of expertise so if it’s hip or knee or spine or foot and ankle we have different providers that do each of that. So that’s been really good. It’s been I’ve been here now this is going on about 18 years. So you were saying we were about the same in the game. So it’s it’s been good. It’s been a great place to practice. So thank you guys very much.