Shoulder surgery?

[Dhinu Jayaseelan]

This past weekend we had some good discussions on the physical therapy management of a number of shoulder related health conditions. While we touched on surgical intervention, we did not explore with depth the complexity associated with the various factors leading to surgical intervention, or the post-operative considerations following shoulder surgery. For this discussion, let’s talk about surgery. Below are some ‘conversation starters’ that could help us understand the role of surgery in the management of people with orthopedic shoulder problems. We can touch on each of the items below, but to start, pick one or two topics that you have a harder time answering and let’s chat.

– What are the pros associated with shoulder surgery? We tend to focus on the risks (e.g. infection, post-operative stiffness, subsequent procedures, etc) but there are a number of reasons why someone would have surgery of their shoulder – what are some of them?

– Sometimes we forget that as part of a healthcare ‘team’ we actually work together with other professions – not competitively against them. What are some of your biases against surgery? Let’s be honest and put out your biases, then, come up with a few specific phrases you could use in patient interactions to recommend surgical consults without your biases coming through.

– We spoke to the lack of efficacy of a variety of surgeries for shoulder impingement. What shoulder conditions have evidence to support the use of surgical intervention? Please come up with 1-2 conditions, and offer a couple citations to support your answer.

– Critical appraisal of evidence is essential to quality clinical practice. What are some of the challenges with research trials investigating surgery versus other interventions?

– What role should diagnostic imaging have in surgical management of shoulder pathology? There are a lot of times where we see abnormality of imaging in asymptomatic individuals – when does imaging become relevant?

Here are a couple of additional articles that don’t necessarily answer any of the above questions, but may be relevant resources:

Are Psychosocial Factors Associated With Patient-reported Outcome Measures in Patients With Rotator Cuff Tears? A Systematic Review

National Trends in Rotator Cuff Repair (2012..)

US Geographical Variation in Shoulder & Knee Arthroplasty

[Sarah Frunzi]

The two questions I was drawn to and want to address most were, “What are the pros associated with shoulder surgery?” and “What role should diagnostic imaging have in surgical management of shoulder pathology?”. I feel these two questions are related to each other. In my experience so far, I have seen where imaging has done more damage by instilling worry, and where more of my time is spent educating on possible normal imaging findings and calming fears regarding imaging results; but for the appropriate patient, imaging can provide possible answers and open opportunities for further indicated treatment that can help the patient return to optimal functional ability. While I am biased towards conservative management being trialed first before seeking surgery, I have had one patient case where surgery was indicated AND he was comparatively better for having it. This patient was in Physical Therapy for a couple weeks with only slight improvement noted when he was then sent by his doctor to receive further imaging. He proceeded to have an MRI performed where he was told to stop Physical Therapy until after he had surgery where he would have his rotator cuff and biceps tendon repaired. This patient is an older gentleman in his late 60’s and is very active outdoors. He is a frequent competitive sailor as well, which he desperately wants to return to. After having his surgical procedure, and post-op Physical Therapy, his shoulder is remarkably better in both pain levels and functional ability. His range of motion and strength are nearly full, and he is looking at returning to sailing at the beginning of this upcoming year. This is the case where I believe the abnormality in his imaging was relevant to his symptoms and impairments, and where surgery was absolutely indicated. In my reflections, I have often wondered to myself, if it hadn’t been for the doctor requesting further imaging, how long would I have kept him in Physical Therapy before I would have sent him back to his PCP to have imaging performed? Would my biases have prevented or delayed him from getting the care he needed? This specific patient case has challenged my biases and has helped me be more open to the option of possible surgery for the patient that truly is appropriate for it. I still believe that good, mindful, and evidence-based conservative management should be trialed first before being deemed “failed therapy”, and all possible avenues of potential pain drivers need to be addressed to the best ability before recommending surgery. However, when this truly is not enough, the patient’s goals are not being met, and symptoms are not improving, I do believe imaging and surgery have their place in patient care; a team based, multi-disciplinary and collaborative approach to provide the best care to make people feel and move better.

[Dhinu Jayaseelan]

Hi Sarah –

Thanks for your post. You offered some examples that resonated with my own clinical practice. In the case of your 60 y/o patient – it’s good that the outcome was positive. I’m wondering – what were some variables you remember that seemed to be associated with this poor outcome with initial management? Limited motion? Severe weakness? Did he have a trauma? Why do you think that the image led so quickly to surgery, when there are a number of studies suggesting cuff abnormalities on imaging are normal in older asymptomatic individuals (Teunis, JSES 2014; Tempelhof, JSES 1999; Minagawa, J Orthop 2013; Yamamoto, JSES 2011). Was this surgeon more aggressive or conservative? Looking back, do you think there was anything you could have detected clinically to say – you know this guy probably would do better with surgery, as compared to someone else with a similar age/activity level?

If some patients, like your boating guy, get better based on management directed by imaging, why do you think there is a hesitancy to use it more regularly to guide management? I’d like to hear more about your perception on why your experience has been more negative in regards to imaging. What are some specific components of the imaging process that can be harmful, do you think? Why do you think you have these negative perceptions? Is it because you’ve seen patients whose outcomes worsened after imaging? Did your professors have a bias that led away from imaging? I’m wondering if you can drill down a bit into why you had that initial bias regarding imaging. These studies specifically come to mind for me – Brady, Insights Imaging 2017; Bedell, JAMA 2004.

We can always argue every patient is an n of 1, but identifying how imaging can be useful is important, since like you and many others, we’ve potentially become biased against its use for a number of valid reasons.

Thanks for your thoughts – looking forward to hearing more about this.

Dhinu

References:
– Bedell SE, Graboys TB, Bedell E, Lown B. Words that harm, words that heal. Arch Intern Med. 2004;164(13):1365-1368. doi:10.1001/archinte.164.13.1365
– Brady AP. Error and discrepancy in radiology: inevitable or avoidable?. Insights Imaging. 2017;8(1):171-182. doi:10.1007/s13244-016-0534-1
– Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. J Orthop. 2013;10(1):8-12. Published 2013 Feb 26. doi:10.1016/j.jor.2013.01.008
– Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296-299. doi:10.1016/s1058-2746(99)90148-9
– Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23(12):1913-1921. doi:10.1016/j.jse.2014.08.001
– Yamamoto A, Takagishi K, Kobayashi T, Shitara H, Osawa T. Factors involved in the presence of symptoms associated with rotator cuff tears: a comparison of asymptomatic and symptomatic rotator cuff tears in the general population. J Shoulder Elbow Surg. 2011;20(7):1133-1137. doi:10.1016/j.jse.2011.01.011

[Sarah Frunzi]

Hi Dhinu!

Thank you for your response. To answer some of your questions, surprisingly there was no severe weakness and strength was overall fairly good before surgery. Some planes of motion were limited and his initial injury, from what I recall, was more of an overuse injury from the sailing position/role he was doing. Both the patient and I were shocked at how abruptly physical therapy ended after receiving imaging results, and I think a few more visits were warranted to see further progress or for at least “prehab” going into surgery. He had not plateaued, but progress was simply slower for him.

I believe there is a hesitancy to use imaging to guide management, especially surgical, because of the known variability with imaging (Brady, Insights of Imaging 2017; Herzog, Variability in diagnostic error rates, 2017). With potential for error and variability in interpretation of results, the risk of having imaging and potential subsequent surgery, does not always seem like the best, especially when Physical Therapists are diagnostically accurate and appropriate with diagnosis and screening (Deyle, The role of MRI, JMMT, 2011).

I have also had personal negative experiences regarding imaging results and the follow up recommendation for surgery when it was not the appropriate next step. These experiences have made me more cautious with the use of imaging recommendations, especially when both instances surgical management was the recommended next step.

We could spend hours discussing this, but these are just a few of my thoughts to answer some of your questions!

-Sarah

References:

1. Brady AP. Error and discrepancy in radiology: inevitable or avoidable?. Insights Imaging. 2017;8(1):171-182. doi:10.1007/s13244-016-0534-1

2. Deyle, GD. The role of MRI in musculoskeletal practice: a clinical perspective, J Man Manip Therapy, 2011 Aug;19(3):152-61. doi: 10.1179/2042618611Y.0000000009.

3. Herzog, R. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period; Spine J. 2017 Apr;17(4):554-561. doi: 10.1016/j.spinee.2016.11.009.

• This reply was modified 2 years, 5 months ago by Sarah Frunzi.

[Dhinu Jayaseelan]

Hmm – that’s a bit strange. I have been involved in a few cases where there wasn’t a specific MOI suggestive of a full-thickness tear, but clinical exam made sense, and no improvement was had after a few weeks. In that case, imaging has been helpful in guiding what ended up being successful surgical intervention. It’s not as common for what sounds like a unilateral (?) decision guided by the surgeon based on imaging – despite the positive outcome.

It makes me wonder what goes on in the MD’s head when looking at imaging. This is also a great example of what seems like ‘experience’ holding up the stool of evidence-based practice. Research is useful, obviously, but past experiences can be equally important. In that way, while I’m not glad you had a negative experience, I’m glad you can bring a different perspective to your patient interactions to allow for informed decision making.

Thanks

Dhinu

[David Brown]

Sarah,

Thanks for your post, I think this is a very interesting case. With only a “couple weeks” of conservative management under the belt (I’m assuming circa 2 weeks?), I feel like it is important to manage expectations in that outcomes from treatment aren’t typically very apparent that soon especially when our goal is strength gains. Did the patient have a sufficient understanding of healing timelines? Also, I understand your position with imaging, unfortunately, if a patient sees an orthopedic surgeon and they are recommended for imaging, we have right then and there lost control of the case and with imaging almost always will come the recommendation for surgery. I am curious if he made the appointment to see this physician after not being satisfied with a couple weeks of PT or if this was the plan all along for him to get imaging this soon after the start of PT. If it is the former, again education of managing expectations of basic tissue healing timelines become very important. Luckily, it sounds like this patient did well post-op and hopefully will continue to do well at follow ups in the future. I think the unfortunate dilemma with imaging is the radiologist knows nothing of the patient in front of them, they only know to read an image, and find anything and everything that is out of the norm. Without the clinical side of the patient, there is no saying the relevance or the impact of what is found will ultimately have on the patient. I think this is another very important piece we need to convey to the patient if there is a sense that they might be leaning towards returning to the referring physician or making an appointment with a surgeon.

[David Brown]

For this discussion I found it to be relevant to me and especially the profession to speak on RTC surgical repair versus conservative management as I encounter this situation frequently with shoulder patients. The questions in the topic that I think will help guide my discussion are the pros to shoulder surgery and the role diagnostic imaging can play in surgical management. I often find patients come to me with shoulder pain and a diagnosis from their PCP or orthopedic physician of a rotator cuff tear and the patient has MRI imaging to back it up. By the time the patient comes to me, they have heard or read the radiologist’s impression, oftentimes seen the word “tear”, and think the only option for them is surgical intervention. I find it to be challenging oftentimes to discuss what we see on imaging doesn’t always mean surgery, especially with mild or degenerative tears, and that oftentimes conservative management can be an effective means of treatment. I often times find myself discussing how most people, especially older adults, almost always will have some RTC partial tearing and it may or may not have anything to do with their pain despite having a radiologist and/or physician endorsing their pain by showing them imaging that shows that the pathology is in the same area as their pain. Moreover, when it comes to partial thickness tears, Mathiansen and Hogrefe in their 2018 review concluded that MRI is not the greatest diagnostic tool when it comes to properly identifying and diagnosing a patient with a partial-thickness RTC tear. This further solidifies my stance of shying away from scrutinizing imaging if no full-thickness tear was seen on the MRI and the patient retains painful AROM of the involved shoulder.
This being said, when a patient has had a violent traumatic fall or there is a full-thickness tear of a RTC muscle as seen on a MRI, coupled with painless PROM and/or lack of ability to move the shoulder actively because the muscle has been compromised, I begin to shift my thinking and conversations with the patient toward the possibility of surgical intervention if conservative management fails. A study by Piper, et al in 2018 supported the conservative treatment route as it did improve patient outcomes for some patients with full thickness rotator cuff tears, but those that did not improve or did not improve enough to meet the demand of ADLs, successfully underwent arthroscopic surgical intervention with positive outcomes. Overall in this study, patients that were operated on had better post surgical outcomes than those that were treated purely conservatively, but both did improve. My takeaway from this is that, conservative treatment is safer and cheaper so there is no reason not to try this management first, but explain to the patient that there are successful alternatives for people in their situation. With overhead athletes, I might be more likely to recommend surgery outright if they are trying to return to sport sooner.
Overall, I think diagnostic imaging plays a great role when guiding surgical intervention with patients with full-thickness tears, and I believe that going the surgical route can lead to positive results and I will encourage this route if conservative management fails or endorse it if the patient has made up their mind about it. The only time I would shy away from it is if there is partial thickness tearing as the likelihood of a misdiagnosis via imaging increases as well as the likelihood and positive conservative outcomes.

Citations:

Mathiasen, R., & Hogrefe, C. (2018). Evaluation and management of Rotator Cuff Tears: A primary care perspective. Current Reviews in Musculoskeletal Medicine, 11(1), 72–76. https://doi.org/10.1007/s12178-018-9471-6

Piper, C. C., Hughes, A. J., Ma, Y., Wang, H., & Neviaser, A. S. (2018). Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: A systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery, 27(3), 572–576. https://doi.org/10.1016/j.jse.2017.09.032

[Dhinu Jayaseelan]

Hi Dave –

Thanks for your post. I think you raise some important questions when it comes to surgical v. non-surgical management of individuals with shoulder problems. One of those questions is the utility of imaging in guiding management. I offered some references regarding asymptomatic individuals with cuff tears in my recent response to Sarah’s post. You brought up the important process of CLUSTERING findings to possibly include imaging, but also physical testing and subjective questioning in the decision making process. Regardless of how Sn or Sp a test is, when we consider the development and measurement properties of tests, we always should incorporate multiple data points.

When it comes to the patient, I’ve learned that they’re completely correct in thinking they should get a repair. If something is broken or torn, it should be fixed. I have a patient now who is a biomedical engineer, shoulder pain x 30 years – he very much thinks pathoanatomically, and it can be tough at times to help him understand the context. Besides evidence – which may be hit or miss in terms of how much patients care about it – what strategies have you used to help people understand ‘normal abnormality’? What additional strategies could you incorporate to improve the understanding of patients who justifiably are skeptical of conservative management in the presence of pathology identified by imaging?

Similarly, what are your thoughts on tear progression? Sure, we can get similar outcomes to surgical management in many comparative studies, but even the long term follow up in those studies is rarely > 5 years. How do you answer the question if a patient says ‘well if it doesn’t get fixed, will it get worse?’. These articles came to mind, but again, don’t necessarily answer the question for everyone (Kim, 2017; Tashjian, 2012; Hsu, 2015). When we say something is safer and cheaper though, often times we consider more of a narrow view of short term. That person who did/didn’t have shoulder surgery isn’t being tracked for a 10, 20, 50 year follow up. I wonder, did that person who had an equivalent or superior outcome with conservative treatment at 1 year go on to develop altered pain processing, or reduced tensile capacity of the cuff leading to subsequent functional limitation, etc etc etc. I don’t have the answers to these questions, but thinking about this stuff helps me to try and understand the patient and surgeon’s perspective, rather than being biased by my own.

thanks – looking forward to following up with this topic.

Dhinu

References:
– Hsu J, Keener JD. Natural History of Rotator Cuff Disease and Implications on Management. Oper Tech Orthop. 2015;25(1):2-9. doi:10.1053/j.oto.2014.11.006
– Kim YS, Kim SE, Bae SH, Lee HJ, Jee WH, Park CK. Tear progression of symptomatic full-thickness and partial-thickness rotator cuff tears as measured by repeated MRI. Knee Surg Sports Traumatol Arthrosc. 2017;25(7):2073-2080. doi:10.1007/s00167-016-4388-3
– Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clin Sports Med. 2012;31(4):589-604. doi:10.1016/j.csm.2012.07.001

[David Brown]

Dhinu,

You bring up some good points when asking how to navigate the difficult conversation pertaining to a patient being skeptical as to whether or not conservative treatment will be successful, especially if their pain is limiting their everyday life to the point where they may not have the time and/or patience to see if their shoulder can experience a positive response to conservative means. I think this would be especially difficult if they are not willing to look into or buy into the evidence based research pertaining to the topic. In a case like this, I would try the approach of “In my clinical experience, many of the tears on imaging do respond well to conservative therapy and can live a near normal life. Sometimes surgery isn’t always the quick fix we like to think it is and can still have lingering pain and affects. And since you’re already here in PT, why not try this route and see how we feel?” This line of reasoning can sometimes work, but if the patient has loved ones or friends that endured similar problems with their shoulders, oftentimes patient’s will purely go off the past experience of others in weighing their decisions and managing their expectations and their mind’s made up more or less before they walk into the room. In a case like this, I will endorse their decision making and move forward in that manner. Now, if the patient was open to listening to what the evidence says, I would explain that yes, there is indeed a gap in ample research pertaining to long term follow ups with conservative treatment so I cannot say with confidence that the way you feel in one year will match the way you feel years down the road. I would also point them in the direction of Gotoh et al’s research of long term follow ups of arthroscopic surgical rotator cuff tears and how the retear rate post surgery is higher than previously thought, especially if there is a significant limitation in external rotation prior to surgery. I would hope this study would help them understand that although, conservative therapy can fail, so can surgical repair, and that if the patient is willing to undergo the time commitment for conservative treatment (I would also explain post-op rehab is also quite the time commitment), then we should at least give PT a go. Thanks for your thoughts and I hope I have sufficiently answered your questions.

Citations:

Shimokobe, H., Gotoh, M., Honda, H., Nakamura, H., Mitsui, Y., Kakuma, T., Okawa, T., & Shiba, N. (2017). Risk factors for retear of large/massive rotator cuff tears after arthroscopic surgery: an analysis of tearing patterns. Journal of orthopaedic surgery and research, 12(1), 140. https://doi.org/10.1186/s13018-017-0643-7

[Sarah Frunzi]

Hi David!

I enjoyed reading your perspective on this topic. As I found, many patients have come in to the clinic, like you have mentioned, already with their diagnosis and imaging to follow it up. However, many of my patients also come in with all of information they have been given and the associated look of lost hope and fear because they feel like surgery is the only option, and many tell me they don’t want it. This is where our utilization of the literature we are discussing here can educate the patient on their situation (whether it be partial-tear or full-thickness) to help reassure them on the best course of action while keeping in mind their goals. I also appreciate the statement you made in your entry saying, “or if the patient has made up their mind about it.” I agree with you that patient perspective is incredibly important, as well as respecting their decision even if we may not agree with it. Thank you for your thoughts and references on this subject!

-Sarah

[Author]

Posts