Dr. Miller: It's not just the surgery on your shoulder, it's what you do after that can make a big difference in how your operation turns out. We're going to talk about that next on Scope Radio.
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Dr. Miller: I'm Dr. Tom Miller and I'm here at Dr. Robert Tashjian and he's an orthopedic surgeon here at the University of Utah. We're going to talk about shoulder surgery and what follows that, in terms of physical therapy, to get your shoulder back in shape. Tell us a little bit about what you can expect after shoulder surgery. Now, my patients that have come to see you who've had shoulder surgery, it takes a little while for that shoulder to get back to where the patient wants it to be, where they have an outcome that is reasonable. It doesn't happen overnight, does it?
Dr. Tashjian: No. So we will really take people through different courses of treatment after surgery and it's really dependent upon what we actually do for them. Oftentimes, people's perception of what their post-op recovery is going to be is very different. They sometimes think that they have small incisions, that the recovery is going to be short, but that doesn't necessarily always go along.
Dr. Miller: So a big part of what you need to do is really tell them up front, even before surgery, what to expect after surgery.
Dr. Tashjian: Absolutely. And I think a reasonable expectation of even what the surgery is about and what their final outcome is going to be is probably the most important part of how they are going to actually do after the operation.
Dr. Miller: So dispelling notions that they'll be back on the pitcher's mound throwing, you know, a full set of softballs at the batter is not going to happen within two weeks?
Dr. Tashjian: Typically not, and so it really depends on what the surgery. We can talk about someone that undergoes a typical arthroscopic rotator cuff repair if you'd like.
Dr. Miller: Yeah, let's do that. Let's start with that because I imagine you do a fair amount of that in young athletes, as well as . . .
Dr. Tashjian: Yeah, more often than not it's actually in maybe the older athlete that actually has a typical rotator cuff tear. Our average age population for someone that undergoes arthroscopic cuff repair is usually in their late 50s or early 60s. Usually, they are active, they have pain at night, and overhead activities and that's really the reason why we're doing surgery.
Most often times if someone's healthy, we will do them outpatient, so they'll come in and go home the same day and they will be in a sling. Post-operatively, we'll treat them with a pain medication, both orally as well as typically an interscalene block. And that gives patients usually about 48 hours of good pain relief after surgery.
Dr. Miller: Now, an interscalene block is where they actually put a little catheter near the shoulder and they inject an anesthetic and that dulls the pain?
Dr. Tashjian: That's correct. It's not directly into the shoulder socket itself. It's actually around the brachial plexus, which are the nerves that actually go down to the arm. And that's placed by the anesthesiologist and it elutes a small amount of local anesthetic over a period of time, that then provides pain relief for them.
Dr. Miller: Now this is a relatively new procedure, I mean, in the last maybe five to 10 years. Is that right?
Dr. Tashjian: The interscalene block?
Dr. Miller: Yeah.
Dr. Tashjian: Yeah. Actually, blocks have been done for quite a while, probably over 15-plus years. But what we do differently here is that all of the catheters that are placed are placed under ultrasound, which is different than other places. And actually, historically, they were done not under ultrasound. The ultrasound provides us the ability to make sure that we are not . . .
Dr. Miller: The replacement?
Dr. Tashjian: . . . and not injuring things at the time when the catheter is placed. And our success rate with that has actually been very high with a very, very low incidence of having a complication or problem. And we've published on that.
Dr. Miller: So the scalene block and the oral medications get you through the perioperative period and I imagine you're keeping the arm immobile for the most part. How long does a patient typically go before you then enter them into physical therapy?
Dr. Tashjian: It really depends on what we're treating. People's rotator cuff tears can be very small, they can be very big, they can be a little bit older patients or younger patients and we really dictate their post-op recovery with therapy based upon all of those factors. So I don't really make a final decision about therapy when we initiate it until actually after the operation so that we know what the tissue quality is like, the tear size, and the repair construct.
And based on that, we usually will move forward with two different directions. One is that someone has a very large tear in an older population that we might be more worried even with a very strong repair that their healing potential might be limited. We actually go slow on their recovery. Usually, the first six weeks, they're in a sling.
Dr. Miller: That's a long time to be in a sling.
Dr. Tashjian: It is. And actually, most patients after Arthroscopic cuff repair, they're in a sling for six weeks. It just depends on how aggressive we are with PT. If someone's younger, has a smaller tear and we know that their healing capacity is probably higher, we usually about two weeks start them on physical therapy with the therapist. But in that older population with a larger tear, usually, we'll wait even till six weeks to actually start their therapy.
Dr. Miller: Now, it sounds like you work closely with physical therapists. Do you work with a certain set of physical therapists that are very used to the kind of work that you do and your other shoulder surgeons as well?
Dr. Tashjian: We do. Actually, the university has a great set of physical therapists. We have therapy facilities all across the valley. And typically, the therapist that work at our main site, which is at the Orthopedic Center down on Wakara, they travel to the other sites to actually give therapy at the other sites as well.
And the nice thing is that a lot of the therapists are divided into teams so there are upper extremity teams, lower extremity teams, spine teams. And usually, when a patient goes to actually get their therapy appointment, they will be automatically placed into a group of therapist that actually have expertise with whatever the problem they might have.
Dr. Miller: So these therapists not only give the treatments that you ask for, but they also coach the patients and make sure the patients are trying to do some of this work at home, sort of follow the exercises and stretching and things, I imagine.
Dr. Tashjian: Absolutely. So yeah. So it's not just working in the therapy with the patient, it's actually instructing them on a home program, which, actually, most of their treatment and their recovery is going to be how well they work at home. They're usually only working once a week or maybe once or twice a week with a therapist, but then . . .
Dr. Miller: The rest is up to them.
Dr. Tashjian: Yeah.
Dr. Miller: So self-motivation is a huge thing here?
Dr. Tashjian: It is a big deal. So usually at six weeks, patients will come out of a sling, they'll start using their arm for everyday activities, light lifting activities. Usually, they can get back to running, jogging, working on an elliptical etc, and then usually, at three months, that's when we'll start strengthening exercises more, let them start getting back into a little bit more sport related activity. Riding a bike on the road, swimming, those are the typical activities that we'll let at three months.
Dr. Miller: How about other types of surgery on the shoulders that you work with and basically have the need for physical therapy after a certain period of time of immobilization?
Dr. Tashjian: Sure. The other major group of patients that I'll operate on people that have shoulder replacements. And the nice thing about a shoulder replacement, even though . . . and this gets back to what we were talking about before that even though it's larger surgery we're actually replacing parts, that the actual recovery can often be shorter.
So the initial post-operative pain medication requirement for patients after a total shoulder is actually much shorter. Usually, by a week or 10 days, patients are usually only taking meds at night and then oftentimes even on Tylenol. They are still in a sling for six weeks, but usually, all of the therapy that I initiate for the patients, which usually is around two weeks we start, is all home-based for the first three months. And so I usually don't send a patient to a physical therapist until three months. And even at that point, probably over 90% of people never go to a therapist. They just do all their therapy at home.
Dr. Miller: That's great. Well, to wrap this up, basically, if you've had shoulder surgery, you need to know that you're in for the long haul with immobilization followed by physical therapy over a fairly long period of time. So if you want a good outcome, you're going to have to follow what the doctor and the physical therapist help you with.
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