The MedRisk Blog
Today, a similar movement away from aggressive surgeries and toward a more thoughtful, PT-focused approach to shoulder and rotator cuff issues is taking place. We interviewed MedRisk Advisory Board member and a leader in shoulder biomechanics research, Dr. Philip W. McClure, PT, PhD, FAPTA, about this developing trend.
The traditional biomedical model of thinking is that if you have pain, something must be wrong structurally. And that if you fix the structural problem, the pain will go away. What that lead to over the years was an excessive use of imaging and surgeries. We see a herniated disk on the MRI and because that’s not “normal” anatomy, we assume that’s what is causing the pain. But what we’ve seen is that surgery to remove the disk material wouldn’t always solve the pain. Sometimes it would help, but often it wouldn’t.
What we know now is that low back pain can’t easily be explained by simple pathological anatomy and imaging. It is an extreme oversimplification of the problem. There are many things that drive LBP including things that can’t be imaged such as inflammatory cascades and neurotransmitters as well as psychosocial challenges. We also know there is an overwhelming number of asymptomatic people walking around with anatomy that would show as abnormal on an MRI.
Well, there has been a consistent rise in rotator cuff surgeries for at least two decades. Part of the increase is the aging Baby Boomer population, but another factor is advances in surgical procedures and, honestly, a legitimate opinion that repairing a small or partial tear early on is an easy fix that could prevent possibly bigger issues later on. And, like LBP, traditional thinking has been if your shoulder hurt and you had a rotator cuff tear, fixing the tear would eliminate the pain.
But surgery doesn’t always solve pain and there are a lot of people out there with tears that don’t have any pain at all. The fact is, the rotator cuff degenerates with age. If you live long enough, chances are you’ll have a tear. And today, we have evidence that people with atraumatic rotator cuff tears (i.e. degenerative tears) issues can get better without surgically fixing the tear.
A surprisingly large percentage of patients–at least 50%–can significantly improve without surgery, and when you look at just atraumatic injuries, the success rate is even higher. While traumatic or acute tears typically require surgery, one study by Kuhn and colleagues showed that six weeks after first participating in an exercise-based physical therapy program with a two-year follow-up, only 25% of patients with atraumatic rotator cuff injuries required surgery. Of those that did elect to have surgery, most made this decision within 12 weeks of initiating physical therapy suggesting that a trial of conservative care does not result in a long period of disability while considering a surgical intervention.
With both LBP and shoulder pain, a significant number of patients respond positively to exercise despite the persistence of a tear or a degenerative disk.
Similar to LBP, the conservative care approach can have multiple treatment paths that work together, but we’ve seen the best evidence for success with exercise. To be honest, we still don’t understand fully the how and the why. What most researchers and physicians believe is that with appropriate training—aka exercise—you can strengthen the various muscles around the shoulder to compensate for the deficiencies in the injured or degenerative rotator cuff and preserve function. There will typically be some residual weakness, but unless you’re throwing a major league pitch or lifting roof shingles over your head every day, 80% capacity is usually more than enough for the average patient.
Yes. Right now I’m working on what is called voluntary activation looking at how well the nervous system can recruit the rotator cuff muscles in the presence of pain. Preliminary work suggests a big part of what happens when you have shoulder pain is that your nervous system inhibits the full activation of the rotator cuff muscles. Over time, those muscles atrophy, but that is secondary to the initial problem. The root of some shoulder issues could very well rest in the nervous system rather than the musculature primarily.
For payers, it could lead to huge cost savings. When someone undergoes surgery, not only do you have the enormous cost of the surgery itself, but the rehab costs are substantially higher than they would be for a conservative care treatment path.
Surgeons, however, are struggling with deciding who to operate on and who is a good candidate for non-operative therapy because there is no consensus, and no clear guidelines exist to guide this decision. A surgeon’s job, by training, is to repair anatomic abnormalities. While a more conservative surgeon might be comfortable recommending PT as a first course of treatment, a more aggressive surgeon could argue they are doing a disservice to their patients by not fixing a tear before it could get worse, requiring more difficult and extensive surgical procedures.
But we saw similar challenges several years back with low back pain. Today, conservative care is clearly indicated—and used—as the initial treatment path for most patients with low back pain. And we’ve learned that things like job satisfaction, social support at home and at work, how patients think about disability, how much diagnostic imaging they’ve received, and any number of other non-musculoskeletal system issues impact pain and recovery. All of these seem to hold true whether you’re talking about the back, the neck, the shoulder, or the knee.
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