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- Welcome my friends to the Bob & Brad podcast
produced by Bob and Brad,
the two most famous physical therapists on the internet.
I am Bob and I exactly one half of the Bob and Brad team.
Today my guest is an orthopedic surgeon,
Dr. Brent Warner,
and Dr. Brent Warner does a lot of arthroscopic surgery.
He does the shoulder and the knee
and even the hip sometimes,
but today we're gonna talk about knee menisci or meniscus
and ACL surgery and also shoulder rotator cuff repairs.
So, enjoy the program
and you'll definitely will learn something.
Welcome to the program Dr. Warner.
- Hi, thanks for having me, I really appreciate it.
- We have about 15 minutes left,
I would like to get into the shoulder too.
So, could- - Yeah, absolutely.
- Arthroscopic shoulder rotator cuff repair.
So-- - Yeah.
- What is the rotator cuff
and what part commonly requires repair?
- Sure.
So, I think most people kinda understand the concept
that the shoulder is a ball of the socket joint, right?
So, the ball sits on the top of the humerus
so that we call that the humeral head.
And then that ball has a a socket
that it comes up against
and the socket is part of the shoulder blade.
The technical term for the socket
is called the glenoid of the shoulder, okay?
Because the shoulder has so many degrees
of freedom of motion there,
part of that is because that socket in the shoulder
is just a shallow DIT.*
I almost think of it like a golf tee
turned on its side.
It's not like a deep cup that really surrounds that ball.
So the ball has to be balanced on that,
that golf tee logan socket.
So what really does a lot of that balancing act for us
is the rotator cuff.
The rotator cuff is made up of four separate muscles,
the muscles all attached to different parts
of the shoulder blade on both its back surface
and then sort of the front surface which is deep,
to your up against your chest wall.
And those muscles then run out from that shoulder blade,
they become tendons
and then those tendons attach to the ball.
And so there's actually four separate tendons,
they all surround the ball.
They blend into one another a little bit
to form literally a cuff of tissue
that attaches to that ball.
So then when you fire those muscles,
those muscles pull on those tendons
and that's what rotates and moves the ball
relative to that socket in all the different directions
that your shoulder can go.
- So the injury-- - I think the next question--
- Yeah, not in the muscle itself,
is it the injury usually-- - Right, yeah,
it's almost always the tendon that gets injured
and typically right at the interface
of where that tendon comes in and attaches to the ball.
You are asking what part of the rotator cuff
is most commonly damaged?
So yeah. - Right.
- It's that tendon part
and as I said, there's four different tendons.
The one that is directly on the top,
towards the front a little bit,
is the one primarily responsible
for raising in the arm up in this sort of a direction.
That one called the supraspinatus.
And that is by far the most common one
that we see sustain damage and tears.
- So I'm sure this depends on how bad the tear is,
but can it heal on its own?
- Yeah, so some lower grade tears, partial tears,
more like tendonitis within the rotator cuff,
we do believe that those have some ability
to heal themselves.
And so for those ones, we most commonly are gonna recommend
nonsurgical type treatments,
that's gonna be things like physical therapy,
being careful with certain activities,
sometimes injections of cortisone
and other things into the shoulder.
And so some of those tears can, we think heal themselves.
Some tears are also, even if they don't fully heal,
they can become asymptomatic.
Not unlike we talked about
with meniscus tears a little earlier,
there's a fair number of rotator cuff tears
and other damage that is seen completely incidentally.
Some studies have said, for example an 80 year old patient,
there's a better than 50% chance that that patient
has a full thickness rotator cuff tear in their shoulder
that might or might not be causing
any symptoms at all. - Wow.
- So, even a tear can't fully heal itself,
if we're able to make that tear asymptomatic
meaning that patient doesn't have significant pain
and they have good function in their shoulder
that can be something you can live with.
Once we get up into these higher grade tears
ones that are most of the tendon thickness
or all the tendon thickness,
those ones are gonna be less likely to heal,
but again, sometimes we can still treat them
without needing surgery.
- So is it okay to wait?
I mean, let's say I wanna see how this does
or is it hard in some cases
where you better get in there and do the repaired?
- Yeah, I think the best distinction there
is whether or not that tear
is more of an acute type of traumatic tear maybe?
So that patient formally had a completely normal
functional shoulder with of no pain
and they had an injury, right?
If they fell or had an accident
and all of a sudden they have pain
and they're not able to move their shoulder,
we know that early surgery for that type of tear
is typically gonna be best.
The number of studies have shown
that when those acute traumatic tears
become more chronic, the likelihood of good healing
and a good outcome can go down.
Probably the more common type of tear we see
is what's considered to be more of a chronic degenerative
or attritional type of tear.
So, that's gonna be one more related to just
a lifetime of being a human being with a shoulder
and using that shoulder for normal everyday things
and work and so on.
Those ones do not necessarily
need immediate surgical intervention.
And a lot of those, it can be treated successfully
with good physical therapy with injections
with pain medications, those types of things.
There are maybe a couple of exceptions to that.
Some very large tears,
we don't like to let those necessarily go for a long time
without surgery, because some tears left long enough,
can actually become irreparable.
Meaning we can't fix them in if that tissue becomes
too scarred or too damaged or too retracted
meaning it has pulled so far away
from the ball. - Right.
- We're not able to get it back where it needs to go.
Sometimes those can, can get
to a position where they're not fixable anymore.
And oftentimes if you get to that situation
that patient's not gonna have a very good shoulder,
a shoulder they're very happy with.
So, some of those we do,
tend to maybe be a bit more upfront
thinking no out surgery for them.
- So in that case, that kinda leads me to my next question.
If you got, I mean, is there times you gotta
really stretched out on muscle to get it back reattached?
- Yeah. and yeah.
Some of these more chronic tears
if they've been there quite a while
and things have started to scar, yeah.
Sometimes it can be fair chore
in surgery to be able to mobilize that tissue
and get it back where it needs to be.
Sometimes that's not too difficult,
other times it can be a real bit of work
and there are some subtle little tips and tricks
and other strategies that we'll employ sometimes
to help better mobilize that tissue.
And it's one of the things that I'm always prepared for
and I also look back at,
be very thankfully to like my fellowship training,
that extra year I spent sub-specializing
in this sort of thing.
Some of the surgeons I learned from they-
With who they are
and they're the big names in my world.
They would see the worst of the worst
and the most complicated
and to learn some of those advanced techniques
and tips and tricks has really saved my skin,
more than once, knowing how to do some of those things,
we've been able to get great results for some patients
with some pretty extensive injuries.
- Well, with a real tight muscle,
would that throw the biomechanics of the shoulder off a bit?
I mean, not really.
- It can sometimes,
muscle thankfully be pretty forgiving.
And so we will see in some instances
where muscles can stretch back out,
I guess is the best term to put it
But you're right,
sometimes if a person has had a lot of tendon lost,
where typically the tendon is gonna have,
a couple of centimeters of length to it.
If that tendon has become damaged and shorten
and we have only a very small
stump left to work with,
you're right, sometimes if we try to repair that directly
we can actually over tension things,
make things too tight and that can lead to stiffness,
to pain, to other things.
And so it is something that I tend to try
to be as careful about as possible in surgery,
not wanting over tension or overtight in someone's joint.
And yeah, I'll admit sometimes that can be
a little bit difficult.
- So, is this a painful surgery?
- Yes. This one actually is.
I've had more than one patient
who's had a variety number of surgeries
tell me that the rotator cuff experience recovering
has been kind of amongst the hardest of them.
Now, I think it's similar to what we've done
with ACL surgery and other knee surgeries.
I think we have seen some real advances in this,
especially over the last couple of years.
Similar to what we do for an ACL surgery,
that patient is gonna be under a general anesthesia
and we're gonna do some form of a regional anesthesia,
a block to numb the nerves
that go to the shoulder and the arm.
With the shoulder, we're actually able to do
a long acting form of that block,
so a medication that's gonna last
for typically the first two to three days after surgery.
And we've been doing that now here at Summit
for the last gosh, four or five years now, I think.
- Sure. - And it has in my mind
been a real game changer for people
and their experience recovering from this surgery.
They tend to get really nice relief of the most severe pain
for that first two to three days.
I think that sort of resets the bar a little bit
for what their expectation is
and what their body has overcome to get through that.
And so I've seen people, coming back to see me
for their first follow ups in a week or two
saying that they took, almost no pain medicine at all
or just took it for a day or two,
whereas I think with more classic techniques
it was not uncommon to see people still wanting
to take pain medicine even two and three weeks
or further - Wow.
from their rotator cuff surgery.
so it has certainly been a good thing
in our practice here,
patients seems to be really liking it a lot.
And I think anything we honestly can be doing
to minimize the number of strong pain medications
people are taking,
I think that's a really good thing,
both through their health
and just sort of public health in general.
We know in narcotics are dangerous drugs
and they can unfortunately get into the wrong hands,
even times with the best of intentions
and can cause all sorts of serious troubles.
So if we can, be good stewards of that
and minimize the number of those we're using for people,
I really think that's an important thing.
- All right.
I want to be very respectful of your time.
So, I'm gonna mention your website again
and how to get ahold of you, Dr. Warner,
in case you wanna have surgery from him.
So, (chuckles)
the best way is www.summitortho.com
S-U-M-M-I-T-O-R-T-H-O.com.
And, he does-
Do you hip surgeries too or not?
- I do. Yeah.
So, I do arthroscopic hip surgery.
So similar to, in the near the shoulder
we can use a tiny camera to guide it down inside
of the hip joint.
And there's a number of different things we can accomplish
with that sort of a technique.
So yes, I do hip arthroscopy
or do arthroscopy of all three of those joints.
- How about elbow?
- I don't do much elbow.
I have several partners that are more sub-specialized
to the elbow all the way
down to the hand and wrist.
And so- - Yeah, gotcha.
Most commonly I'm gonna pass those patients
along to those specialists.
- Well, thank you again Dr. Warner,
very impressive, great information
and I hope some people will check you out
because you're in that, again in that zone.
(chuckles)
A lot of surgeries, but you're young, so-
- Yeah, yeah.
- Thanks.
- No, thank you so much for having me.
It's been fun.
I really, really appreciate it.
- Yep. Thanks for on.
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