Ortho Eval Pal: Optimizing Orthopedic Evaluations and Management Skills
Be inspired by Paul and his experience with evaluating and treating orthopedic injuries. Learn about everything orthopedic from plantar fasciitis to cervical spine pain, how to communicate with specialists better, optimizing your evaluations and so much more!
Ortho Eval Pal: Optimizing Orthopedic Evaluations and Management Skills
Painless Rotator Cuff Tears: To Repair or Not to Repair? | OEP374
In today's episode I discuss...
-Who is at highest risk of RCT’s
-Clinical Exam vs MRI
-Pain vs function
-Advice we might give patients trying to decide if surgery is appropriate and so much more!
💥LIVE Shoulder Course Info May 2025
✅Are you looking for One on one Coaching? We have it!
✅ Hop onto our email list? 👉👉 Click HERE
Say "Hello" to RangeMaster, our new show sponsor.
👉Get your FREE BlueRanger Pulley: email Jim@myrangemaster.com and enter Ortho Eval Pal in the Subject line.
Support OEP today!
Want to join the OEP community? Click HERE to jump onto our email list. SUBSCRIBE at the bottom of the page.
Ask me your ortho evaluation questions and I will answer them on the show: paul@orthoevalpal.com
Come visit our WEBSITE!! Click HERE to check it out
Be sure to "follow" us on our new Facebook Page
I finally made it to Instagram. Stop by and check us out
Are you looking for One on one Coaching? We have it!
Be sure to check out our 500+ videos on our YouTube Channel called Ortho Eval Pal with Paul Marquis
#rotatorcuff #podcasts #PTpodcast #medical #health #orthopedics #Physicaltherapy #DPT #Medicalproviders #sportsmedicine #athletictraining #chiropractic #occupationaltherapy
- Thanks for listening!
- If you like our podcast, be sure to check out more of our great content at OrthoEvalPal.com, Instagram and Youtube.
- We'd love a rating or review on your podcast platform.
- And, as always, be kind to each other and take care!!
Hello everyone and welcome to episode 374 of the OrthoEvalPal podcast. I am your host, Paul Marquis, and I'm a physical therapist. Today we're going to be talking about the painless rotator cuff tear and how to manage it. We're going to be talking about who's at highest risk of rotator cuff tears. We'll talk about the clinical exam versus MRI, pain versus function advice we might give our patients, you know, when trying to decide if surgery is appropriate, and so much more. But before we get started today, I just want to mention our sponsors. We have range master.
Speaker 1:Range master is known for their shoulder rehab equipment. They offer products from shoulder wands to finger ladders, overhead pulleys to shoulder rehab kits. Range master is your one-stop shop to help with the treatment of frozen shoulders, post-op rotator cuff repairs, total shoulder and reverse total shoulder replacements, and so much more. If you'd like to get a free sample of Rangemaster's Blue Ranger pulley system, just email jim at myrangemastercom and add OrthoEvalPal in the subject line. Now we also have MedCorp professionals. Now I know the folks at MedCorp Personally. They are locally owned and a family-operated medical supply company. They carry everything from radial pressure wave units to traction devices, resistance bands to compression garments. Most impressively, though, is their customer service. It's second to none. I know these folks personally. They are great to work with and do an awesome job at getting the right products to you and to your patients at a very efficient time. They are second to none. If you're looking for medical products for your clinic or products for your patients, go to wwwmedcorprocom and if you use coupon code OEP10, you can get $10 off a Sondra cervical traction unit and if you use coupon code FIRSTTIME10, you can get $10 off your first order at Medcor on other products. Welcome back everyone.
Speaker 1:Oh boy, is this going to be a little snowball episode? I'll tell you, and you know, it's one of those episodes where I have this idea I want to talk about this. It's like simple. I'm like this is gonna be like a 10 minute episode and it just rolls and rolls and rolls and I just want to keep going with this and I just want to get into my life course. I'm going to be giving in a couple of months and just go on with this stuff. Um, so where do we even start? Okay, I want to talk about rotator cuffs today. And we are. We're going to a place where nothing is black and white today, Okay, and you may get done with this episode and say I can't believe I listened to this, Like I don't know if I got the answers I was looking for when I got into this episode.
Speaker 1:There's going to be a lot of gray area here, but one thing you need to remember is that every single patient who comes in with a rotator cuff problem or a shoulder problem is different than the previous one that you saw. I tell patients this all the time. I could have a hundred rotator cuff tear patients standing side by side. They will all present differently as far as active range of motion, passive range of motion, pain levels and function. They will look different and I will treat every single one of them differently, Okay.
Speaker 1:So if you think you're going to come to a course and you're going to get the one answer for your rotator cuff tear patients, you're at the wrong course. Okay, we need to teach you how to individualize, how to manage these people. Okay, Cause they're all so different. I mean, think about it. There are two over 250,000 rotator cuff repairs done every year in the United States. 40% of people over 60 years old have a rotator cuff tear. Okay, Now, that could be symptomatic or asymptomatic. Now, if you take 100 people that don't have shoulder problems and you MRI them or do a diagnostic ultrasound, you'll find that 40% of those people will have partial rotator cuff tears and up to 46% will have full thickness rotator cuff tears, but they're asymptomatic. They wouldn't even know that they had it.
Speaker 1:Okay, so I can't even, you know, try to figure out how many patients with rotator cuffs I've seen over my 33 years of being a PT. I know that, like if I were to throw all shoulders together, I just couldn't even put a number on it. It's astronomical, From frozen shoulders to impingement, to proximal bicep issues, to labral tears, you name it. But we do see a tremendous number of rotator cuff tear patients. I think we had like seven or eight in the clinic the other day, you know, pretty much all in one morning amongst the therapist and myself who were in that clinic. So I've seen a lot of them.
Speaker 1:One thing I'm going to try to instill today is, you know, treat everybody individually if possible. So what I want to do today, too, is I want to discuss my thought process on how I manage these patients who have, more specifically, a non-painful rotator cuff tear. Okay, so I'm going to start here with a patient presentation and it's a 54-year-old male and it's not me, although I do have a small rotator cuff problem which I'm working on right now, but it's coming along nicely. So, but we do have a 54 year old male who I bump into at the redemption center, knew this guy from a long time ago. I'm like, hey, how you doing? And he's like great.
Speaker 1:But I just said I just recently hurt my shoulder and I'm like, oh really, no kidding. I said try to lift your arm. And he couldn't like lift his arm off his side. It was crazy. So I suggested he come see me.
Speaker 1:I took a look at him. I was 100% sure he had a rotator cuff tear and so I set him up with an orthopedic surgeon and he met with this surgeon and the surgeon says you know, have you ever had a rotator cuff tear in the past? And he said yes. He says well, he says I suspect that I did. He says well, he says I suspect that I did. He said I had three episodes that hurt my shoulder, but each time I did it I lost more and more function. And so, you know he, the surgeon, said well, you know, you have a MRI diagnosed rotator cuff tear. You clinically look like you have a rotator cuff tear, we can do surgery anytime you want. And so he came to me and said I really need your opinion on this if I should have this or not.
Speaker 1:And so his worry is that he the length of time to recover and the pain associated with the surgery. And he reports to me that, even though he can't use his arm very well, he doesn't have any pain no nighttime pain, no daytime pain. I ask him about pain with function, he says he doesn't do much. He uses a computer at his work, he's a minister on the side and he just doesn't do a lot of physical activity around the house. He says I I can do everything I need to do, I can take care of myself and I just don't have this pain and I don't really want to undergo. He said I've seen people who had rotator cuff repairs done before and they're in severe pain for a long time. They're in a sling, you know, and they're really out of commission and whatnot.
Speaker 1:So let me just paint you the physical picture of this gentleman. He has active flexion of about zero to a hundred degrees, abduction zero to 80 degrees, external rotation to about 45 degrees. This is all actively Internal rotation to about 60 degrees. Now his passive range of motion is significantly better, but he does have a little bit of capsular tightness at the end ranges, and he should right, Because he hasn't been lifting his arm overhead, he hasn't been reaching way behind him to put his jacket on, because he just can't move that arm that much and so he just doesn't go there. So we expect his capsule to be tight. All right Now. Manual muscle testing is pretty awful. Flexion abduction three minus over five. Obviously you can't even get it to full range of motion. External rotation two plus to three minus over five max. Now when I resist his flexion abduction, external rotation, he has a significant shoulder hike. Internal rotation is about 4 plus over 5. He has very poor humeral head depression. His cuff is not depressing his humeral head whatsoever. So the patient asks me what do I do?
Speaker 2:Glass Training and Education provides unbiased, comprehensive CEU courses in the blood flow restriction training modality. This master class in BFR is for practitioners who want to stay on the cutting edge of rehab and performance. Using BFR has diminished rehab times while improving musculoskeletal and cardiovascular outcomes utilizing minimal equipment. Online, in-person and hosting course options are available. Visit glasstrainingandeducationcom and use discount code BFR50 to receive $50 off your course purchase. Learn from experts in the field and feel confident in using BFR to take your patient's outcomes to the next level today.
Speaker 1:Well, folks? Number one is it my place to tell him what he should do or he shouldn't do? Now I know he comes to me. He says listen, I know you have a lot of experience. I totally trust you. You have great rapport with your patients and great outcomes. And I'm not patting myself on the back. I'm telling you what the patient is telling me and I've seen a lot of things and I've learned a lot of things when I was a young therapist and I really was able to sort out a lot of these things a little bit easier. But oftentimes there is no definitive answer. So is it my place to tell this patient yeah, you should go ahead and have your rotator cuff repaired, because we know there's a high risk that you're going to develop osteoarthritis of your shoulder early and that could be a problem. Maybe he'll develop some atrophy, some weakness, maybe later on develop some pain. Number two do we try conservative treatment and see what happens, or do we just wait and see how this transpires, if he goes on with his everyday life and maybe we check him out in a month or two months and and see how it's? It's going okay. So he's 54 years old, he has no arthritis. He doesn't have pain and functionally he can get along. So what do we do? So my question to you is do all rotator cuff tears need to be repaired? And the answer is no.
Speaker 1:I have a patient now who came in with he was in terrible shape with a torn rotator cuff and a labrum. He opted to try PT reluctantly. His doctor said, well, let's try some physical therapy. And obviously when I saw him he had a torn cuff, he had issues with his labrum, he had significant loss of motion. He first, when he first tore it, he had a big fall and he said his pain was severe. For a day or two he could not lift his arm and then for about a week it got better and better and better and then he could start to lift his arm a little bit better and then it just got progressively worse after that. So he came to see me. I want to say it was four or five months after the onset of this injury and he was just miserable. And I said I educated him about you know what a rotator cuff tear is, what a labral tear is, and that I've had many patients, even in the last couple of years, who have complete rotator cuff tears who get better and they're comfortable and they're fine. But if they don't get better, then we have the option of surgery. So he opted for physical therapy reluctantly, and within two visits he was significantly showing improvement in regards to his function. And what had happened was he had developed a frozen shoulder after the injury. So not only did he tear his rotator cuff in his labrum, but he developed this frozen shoulder. That that's why he got better at first, and then he progressively got worse and the arm got stiffer. So he managed his adhesive capsulitis and guess what? He started to develop better and better range of motion. He's 95% better now. I saw him just a couple of weeks ago and I'm going to do a check on him in another month just to see how he's doing. But he told me I can comfortably live the rest of my life like this. He says I don't want to have surgery, I'm very functional, I'm a pharmacist, I also do a lot of work outdoors on the side and I can do everything I want to do.
Speaker 1:Okay, so the next question I have for you, my audience, is are there problems with waiting to have a rotator cuff tear, a rotator cuff repair? And you know this is a question that I brought up to a surgeon on a podcast that I did previously back in in my earlier days and remember this, I am not a surgeon, but we know some of these things. This is just how it happens. When you tear your rotator cuff, that rotator cuff if it's a full thickness tear can retract, okay. So basically like an elastic that you stretch out and somebody cuts one end, it pulls back and recoils and retracts. So it makes it harder for a surgeon to put back in place. The longer it stays retracted, the tip of that rotator cuff tear might start scarring down. Is that going to heal? Well, when they put that back in place or when they repair that? Will this patient start to develop some labral and glenoid erosion? If the rotator cuff is not depressing the humerus, then that humerus is going to start to erode that superior glenoid and eat out at that labrum and you basically get this shifting and this grinding of the joint and will the patient develop some atrophy which could make it difficult down the road if they do have that rotator cuff repaired to get this rotator cuff active again and get the periscapular muscles back on track. So these all make it more challenging and more you know, for the optimal surgical outcome. So that's something you need to take into consideration and so I give some of these scenarios to the patient. I prefer that the surgeon give this scenario to the patient, but again, we don't want to scare the patient into having surgery.
Speaker 1:Okay, because I've seen both of these cases. You know where I've had a patient with a 15-year-old rotator cuff tear and they have it repaired and they have an excellent outcome. And then I've seen patients who have the repair right after the injury and do poorly. There are so many factors. You know the surgical repair itself, the technique of the repair, and you know was there a good purchase of the rotator cuff? Is there a good tissue integrity? Are you repairing two pieces of leather together? Are you repairing wet toilet paper? You know patient age comorbidities, do they have diabetes? Are they smokers? You know all of these things can make a huge difference when you know not having a rotator cuff repair. So we don't always know how this is going to go.
Speaker 1:So I have this other patient here and I don't really I mean, I could go on, I have years worth of patients, but I have this patient right now. His name is Al, he's soon to be 80 years old, he's extremely active, he likes to bowl, he likes to fish, um, and he likes loves to golf. This guy was a weightlifter and he could. I remember him bench pressing over 300 pounds at 65 years old and he today told me that he continues to curl 25 pound dumbbells on a regular basis and he does, you know, basically dumbbell presses with 30 pounders and just does his best in the range that he has. He just likes, he's always liked to weightlift and so he just underwent a right CMC arthroplasty. And he's a bowler, so he can't bowl with his right hand right now, but his goal is to be able to bowl, you know, next winter.
Speaker 1:And his left shoulder is is shot, and when I say shot, I mean he has 0 to 10 degrees of flexion, 0 to 10 degrees of abduction. If I lift him up, he has a positive drop arm test. He has considerable shoulder hiking. His external rotation is 2 plus over 5 max. Internal rotation is 4 over 5. He has a massive rotator cuff tear Passively full range of motion.
Speaker 1:And he does have some arthritis in the shoulder which is demonstrated through an x-ray MRI. He has no pain but he has no function okay and he wants to have surgery. He wants to be able to golf again and so he's had an attempted rotator cuff done I want to say eight or 10 years ago and it failed. They could only partially repair the cuff. The integrity of the tissue was awful and it just did not take. So at this stage of the game he needs a total shoulder, a reverse total shoulder arthroplasty, because his cuff is not good, he has bad tissue integrity and he has arthritis in the shoulder. So he's going to be and he's otherwise healthy, so he he is going to do very well with a reverse total shoulder arthroplasty.
Speaker 1:So everybody's situation is different and you need to treat each one of them individually and you have to respect what patients tell you. So, even though you know it may not be the best decision, if they're not in a significant amount of pain and they are functioning and they can take care of themselves, then, icing on the cake you know I have a list of patients in front of me right now. I can go through these stories of you know a Border Patrol agent who tore his rotator cuff. He was lined up for surgery along with this 80-year-old Priscilla, who was lined up for surgery. Also, both of them came into PT at the same time. They both did extremely well. He went on to weightlifting like he used to do in the past and continuing on with his work with no pain, full function. And Priscilla has 80% of her shoulder function but she's like I'm not in a lot of discomfort and I can take care of myself and help my husband and I can drive and I can do whatever I need to do, happy to not have surgery.
Speaker 1:Okay, so we know that pain is a big driver towards surgery, uh, but you know a lot of people can have pain coming from somewhere else. So it's very important that if you do deter, if you do decide to treat these folks conservatively and you know they have rotator cuff tears and maybe they're they're not painful then you need to monitor them often. You need to make sure they don't have an underlying nerve injury like a suprascapular nerve injury or an axillary nerve injury or something like that. A C5 nerve root compression can look just like a rotator cuff tear, parsonage, turner syndrome. I mean we've seen all of these just in the last couple of weeks, and so you need to make sure that they don't have another underlying condition that causes them to look like they have a rotator cuff tear, all right. So if you do treat them conservatively, monitor them often, look for some improvement.
Speaker 1:You don't want to see regression in these patients, but if they're not coming along, it's time to meet with the surgeon again and have a conversation on. You know, do you want to have less pain and do you want to have better function, and how do you increase that chance of that happening? So you know patients should know the facts, but they should not be scared into having surgery. So I have a lot of experience with patients who have had shoulder problems. I've seen many scenarios and I've seen what works. I've seen what doesn't work. But again, like I said earlier, nothing is black and white when it comes to treating shoulder patients. Okay, so I hope you enjoyed today's episode. I know I threw a lot at you. I know you may not have the answers to everything. I love to do online coaching and answer those questions. You know one-on-one or you bring your patient scenarios to me.
Speaker 1:We have a discussion on how to manage them better. Maybe we go through an anatomy review. We talk about anything orthopedic, pretty much from evaluating patients to how to connect with shoulder surgeons and other specialists out there who you want to work with. If you are interested in a live shoulder course, I'm going to be giving one in May of 2025 in Auburn, maine. So you just check out the links in the description and you can click on that if you want more information, such as the agenda or the location, the time and things like that. So we do have a few spots available. If you're interested, feel free to jump in. I'd love to meet you and talk shoulders If you want to see some real patients with real diagnoses I know not all of them are in 4k, some of them are old We've had our YouTube channel going for 13 plus years but you can take a look at some of these patients with some of these diagnoses of reverse total shoulders, rotator cuff repairs, major tears, bicep ruptures, you name it.
Speaker 1:We have it. Just Google Paul Marquis and the diagnosis and it'll pop right up or hit the links in the show notes and that'll take you right over there and I hope you enjoy those. But with that being said, folks be kind to each other and take care.