Shoulders a Big Responsibility

Tuesday, January 9, 2018

Leading surgeon discusses latest treatments for shoulder problems

By Kevin McKeough

Anthony Romeo, MD, watched the recent World Series with particular interest. A specialist in shoulder and elbow surgery, Romeo treats many well-known Major League Baseball pitchers and other players. He is one of the doctors at Rush who serve as a team physician for the Chicago White Sox and the Chicago Bulls, and he also provides care for numerous athletes from other teams and sports.

In addition, he’s a nationally recognized leader in his field: Romeo started his one-year term as president of the American Shoulder and Elbow Surgeons in October.  

Here, Romeo discusses common shoulder ailments that affect tens of millions of people in the United States, the current and emerging treatments for them, his work with professional athletes, and the ASES, a prestigious professional society with more than 700 members.

How prevalent are the problems you treat?

Romeo: Anywhere between one in three to one in six adults in the United States — somewhere between 50 and 100 million people — deal with shoulder pain on a regular basis. Even though so many people experience shoulder pain and shoulder impairment, because we don’t walk on our hands and can do so many things with our arms at our sides, patients learn to deal with shoulder discomfort and generally tend to avoid surgery.

Who is most at risk of injuries?

The biggest predictive factor is age: As we go through life, the risk of having a problem with arthritis or a rotator cuff tear increases.

When we’re teenagers and in our early 20s, some common shoulder problems are that it is too loose or it gets out of place. When we get into our 30s and 40s, we start to experience tendonitis. We start to see rotator cuff problems in our 50s, and they tend to increase throughout the decade. Shoulder arthritis tends to affect people in their mid-50s to mid-60s, with the average age of people undergoing shoulder replacement surgery in the early 60s.

Are there other risk factors?

There is an association with people who do very strenuous activities or overhead activities developing problems with the rotator cuff. Construction workers, or people working as a baggage handler at the airport have increased risk of rotator cuff injuries because the work they do affects their shoulders. Baseball players, if they’re not careful, can develop rotator cuff problems.

What are the consequences/effects of these injuries on patients’ function and quality of life?

These problems typically affect individuals that are active, that are participating in either daily activities around the house, or recreational sports or work responsibilities that initiated their problems. Their primary concern is pain, which gradually can affect every aspect of life, including the ability to sleep at night.

The patients who come to me with rotator cuff or shoulder problems say they can deal with the pain during the day. Their complaint is their inability to sleep at night.

What are the typical treatments for these injuries?

When people come to us with a rotator cuff problem in their 40s and 50s, if there hasn’t been a specific injury that caused the problem, if it’s been more of a repetitive activity, we definitely pursue a course of anti-inflammatory medicine and physical therapy in an effort to reduce the inflammation, stabilize the shoulder and get motion back.

When the tendon goes on to tear, especially if it occurs after a sudden event, such a skier falling to the ground and hitting his shoulder very hard, that’s a more challenging issue, especially for our younger patients to tolerate. It’s very painful, it interferes with their sleep, and these tendons don’t have the ability to heal on their own. If they chose to live with it, they’re choosing to accept a life of discomfort and impairment that is permanent.

For patients in their 30s and 40, surgery to repair the rotator cuff is recommended. The most common situation we see with patients in their 50s and 60s is chronic strain of the rotator cuff tendon. What we’ve learned is that 75 percent of these individuals can undergo physical therapy and anti-inflammatories and live with it, even with a rotator cuff tear.

Unfortunately, that means 25 percent, one out of four, don’t do as well, and they seek surgical treatment. It repairs the tear, and it is an outpatient surgery. Patients can manage the pain at home using a multi-analgesic program we set up for them, and they start physical therapy in a week’s time.

What does a rotator cuff repair surgery involve?

When the rotator cuff tears, the tendon pulls off the bone, and it can’t grow back into place by itself. What we have to do is reattach the rotator cuff tendon where it was torn from the shoulder. We have special devices that fix the tendon to the bone, so that the tendon and bone can grow together.

The real problem is that rotator cuff tears do not heal easily. When we repair a rotator cuff tendon, we have to ask the patient to not use their arm for six weeks. That can be really challenging. For the next six weeks, they’re only able to do the most simple things in terms of their care.

In three months, we start to strengthen their shoulder. The average time it takes for patient to get back to normal is six months, but it can take a year. That’s a very challenging course of recovery for patients, but that’s the nature of rotator cuffs, and that’s how we manage those problems.

What about arthritis? How do you treat it?

Shoulder replacement surgery is very effective in relieving pain, and restoring movement around the shoulder. This operation works exceptionally well for patients in their 50s and 60s who have a functioning rotator cuff.

But some patients not only will have arthritis, they’ll also have rotator cuff problems. The combined problem is really debilitating.

Fortunately, we have procedures that use a specially designed prosthesis (artificial shoulder joint) that allows patients to function even if they have a rotator cuff problem. It works exceptionally well for individuals who have this complex problem.

How are the treatments for these problems changing? What are the latest advances?

We have developed a very sophisticated way to repair rotator cuff tendons, which has improved our ability to get a good result in surgery. However, many patients and doctors don’t realize that about one out of five rotator cuff repairs aren’t successful in getting the tendon to heal back to the bone.

We’re working on some new advances to get those tendons to heal. At Rush, we’re involved in a bone marrow stem cell study that’s using biologic enhancements to get the tendon to heal properly.  I think we’re very close to developing a biologic device that enhances body’s ability to heal tendon to bone.

For our younger patients who have instability in the shoulder, for years we were performing an arthroscopic procedure to repair the ligament. We’ve learned that some of the young athletes not only have injured the ligament, they also have injured the bone. We’ve learned that if they have this defect, the arthroscopic procedure doesn’t work very well.

For those individuals, we have a special operation to restore the bone and the stability of the shoulder that allows them to go back to activity. In even the highest level athletes, we have learned how to restore bone loss so they can get back to their normal lives.

We really have made tremendous advances in shoulder arthritis in the last 15 to 20 years, and I’ve been fortunate to be part of that. It used to be that the prosthesis was designed for the general population, and it was up to a clever surgeon to adapt it to the patient. We’ve learned to design prostheses that match our patient’s anatomy very accurately.

Many patients come in thinking they’re going to have a shoulder replacement, assuming it’ll change their lives for the worse, and when I’m done explaining it, they realize it’ll change their lives for the better. They’ll have less pain, they’ll be able to get back to activities, including swimming, golf and other activities that demand extensive shoulder movement. For many, it’s a new lease on life.

Talk about your role as president of American Shoulder and Elbow Surgeons. What impact do you hope to have?

We’re developing a new curriculum for shoulder and elbow fellows (doctors receiving subspecialty training) throughout the U.S. We are starting a new area of political advocacy where we’re spending more time with our congressmen and representatives, which I’ve done many times this year, to share with them the challenges our patients have and how we can help them.

Our government has not decided to reimburse shoulder replacement in the outpatient environment (for Medicare and Medicaid patients), but we’ve been able  do this surgery in outpatient settings with many patients who have private insurance to make sure it was safe, reliable, and that the cost was dramatically less.

Our society’s goal is to become a global leader of shoulder and elbow education as well as advocacy of things we do in our profession.

You’re among the doctors at Rush who serve as team physicians for the Chicago White Sox. What’s it like to be involved in the players care?

It’s been a real honor to develop an expertise and a reputation for being able to get athletes back to return to sport after shoulder and elbow problems. That has been a reward of my work with my partners taking care of the White Sox in particular, but I also see many collegiate and professional athletes in my office for consultations, including professional tennis players, professional football players, including one who won an MVP award after I operated on his shoulder.

Working with these high-level patients spills over to the care of all my patients. I’m going to treat you just like one if them in terms how I’m going to repair your rotator cuff or fix your shoulder, because I’ve learned what it takes to get back to highest level, and I’m going to apply it to your shoulder.