The MRI may have been the Tail that Wags the Dog

[mtomaino]

Yesterday I saw a 63-year-old male patient who came to my office for a second opinion regarding his right shoulder. He had been raking leaves recently and had discomfort. He shared with his primary care doctor that his shoulder began hurting since a fall for about 2 years, intermittently. An MRI was ordered which to everyone’s surprise revealed a large, retracted supraspinatus and infraspinatus rotator cuff tear, a near complete tear of the subscapularis, and significant atrophy of the supraspinatus, infraspinatus, and teres minor muscles. There also appeared to be superior migration of the humeral head and significant cartilage wear involving the humeral head and the glenoid.
Based on the severity of the MRI he was urgently referred to an orthopedic surgeon who strongly recommended arthroscopic surgery; he was advised that repair might not be possible, that a partial repair might still be better than no repair at all, and that he was too young for reverse total shoulder replacement. This patient had a lot of unanswered questions, and that was really the reason he sought a second opinion from me.
In preparation for his visit I had reviewed the MRI, and the fact that he had retraction of his supraspinatus and infraspinatus to beneath the acromioclavicular joint suggested that this might be chronic, and less likely fixable. The additional finding of severe atrophy was consistent with chronicity— and in light of the evidence that atrophy, and age above 60, and large tears are risk factors for not only poor healing potential, but also poor functional outcome if healing were to occur— I was prepared ahead of time to advise against arthroscopic surgery, in favor of reverse shoulder arthroplasty even though he was in his 60s. Indeed, as implant designs have improved over the last few years the indications for reverse shoulder replacement have clearly broadened to include patient’s in their 60s and even younger, when no other options exist.
Now to the most important part of the decision-making process— speaking with him and the results of his physical examination. He expressed to me no problems with function except after an hour or 2 of overhead work. Although he had discomfort in the shoulder during those types of activities, he had been living with an ache that approximated an average of 2 out of 10 over the past 2-3 years. The only reason he saw his primary care doctor recently, which led to the MRI, is that his shoulder started to ache after doing yard work. On physical examination he not only had full overhead flexion, but absolutely full and symmetrical external rotation without a lag. In addition, he had no weakness on testing of forward elevation or external rotation. And, the belly press and lift off signs were not consistent with subscapularis weakness. Lastly, his plain x-ray showed just mild arthritis and minimal superior elevation-with mild narrowing of the acromio-humeral interval only.
In a nut shell, I shared with him my opinion that it would be very difficult to improve his function-which at this time was very good. The issue of restoring pain relief was a bit more difficult to address. So while I told him that arthroscopy might allow some debridement, and that a biceps tenotomy might be helpful in terms of pain relief, I did not tell him that a rotator cuff repair was likely possible, or that his pain would get better if the cuff repair was possible. And I cautioned him that any attempt at mobilizing and fixing the tear might leave him with worse function because of the mandate for several months of guarded motion to allow healing. In other words, he might develop significant stiffness. I also acknowledged the poor functional potential of the muscle given the severe atrophy. So my recommendation was premised a bit on “option theory.” Do we do an operation today to give an option in the future. Or, would not doing an operative procedure today deprive him of an option in the future. My recommendation to him was that doing an operation today would not burn a bridge of having a reverse shoulder in the future. And because I didn’t think a repair was possible today, not doing an operation today would not impact on the ability to have a repair in the future, or for that matter, the potential that a successful reverse shoulder could be done in the future.
Being absolutely patient centered, I asked if he was having enough pain to want an operation today. His answer was “no”. And so, he was actually relieved that he did not need an operation, and that I was not recommending an operation. I shared with him that it was certainly possible that his function might decline in the future, and in that case, I expressed willingness to see him, consider a cortisone shot, consider some therapy for scapular control-which can often help in rotator cuff deficient patients who have well centered humeral heads--and even talk about arthroplasty. As it stands currently, for patients in their 60s with full overhead motion, good external rotation, irreparable supraspinatus tears, and glenohumeral arthritis, hemiarthroplasty may be a very reasonable option, using an extended articular surface, and a platform that would allow easy revision to reverse type design down the road if needed.
So in conclusion, this patient had a very informative encounter with me, which took about 45 minutes. As an orthopedic hand, shoulder, and elbow specialist, I felt grateful that I could be of assistance in helping him--even though it did not involve doing any surgery. In today’s paradigm where we are forced often to see more patients in a day than we would like, this was a reminder of how easy it is to help a patient without any technical skill so long as we are willing to spend enough time, be present, and listen effectively.