San Antonio Express-News (Sunday)
Regaining shoulder function slow after rotator cuff repair
Q: I had an MRI that showed three of my four rotator cuff tendons have complete tears. I can only lift my right arm midway. I cannot comb my hair, and I’m right-handed. I cannot lift a glass or coffee cup to put on a shelf in kitchen cabinets. I have some pain if I move my arm too much, but Advil helps. Can you tell me what to expect after surgical repair?
V.K.
A: The rotator cuff is a group of four muscles (subscapularis, supraspinatus, infraspinatus and teres minor) that attach the arm to the torso. Any movement of the arm or shoulder needs to be balanced by the rotator cuff for the shoulder to work properly.
Shoulder cuff issues are the most common cause of shoulder pain. But the most common rotator cuff problem is not a tear but damage to the tendons without a complete tear. This is usually treated by physical therapy and sometimes joint injection.
An acute, full-thickness tear in a person with an otherwise normal shoulder is usually treated with immediate surgery to prevent muscle atrophy and further joint degeneration. Full-thickness tears in a person with existing rotator cuff disease and who have new limitations in shoulder movement are also usually treated surgically.
The goal of surgery is to restore as much function to the shoulder as possible, and my experience with my own patients who undergo shoulder surgery is that most function can be restored. However, it can be a long road to get there, with physical and sometimes occupational therapy after surgery.
Some older patients with full-thickness tears nonetheless have pretty good function of the shoulder. Conservative therapy (with the very same experts in physical and occupational therapies) can be effective. Surgery should be considered only in those who don’t respond to therapy and medication.
Q: A friend of my 31-yearold daughter has just been diagnosed with visual snow syndrome. He is devastated, since his profession depends heavily on being able to see clearly. I understand that the disease is not physiological but rather neurological. Is this disease incurable? Is there a genetic link? Do you know of any studies underway?
C.S.
A: Visual snow syndrome is new to me. It is a rare disorder where people notice snowlike dots throughout the visual field. It can sometimes begin in childhood, and apparently there are adults who can never recall having vision without those kinds of dots, which can cause significant loss of visual acuity (and psychological consequences, as you might well imagine).
A 2017 review of the condition identified this as related to, but distinct from, migraine with aura. They proposed two treatments: one medicine normally used for seizures, lamotrigine, and another used for migraine (among other conditions), verapamil. The authors noted that this does not cure the disease but can improve vision significantly enough to
make a real impact on people’s lives.
A second review from 2020 suggested medication therapy is unfortunately not effective much of the time, and it also suggested the wearing of colored glasses (blue-yellow) as being helpful in some people with this condition.
I did find a trial in Colorado recruiting patients for transcranial magnetic stimulation for this condition. You can find it at clinicaltrials.gov.
Q: I am now 78 years old. My mother’s two brothers died of heart attacks at 55 and 65, so when I was in my 50s, I had a calcium scan of my heart. Since then, I have been taking 10 mg of atorvastatin along with blood pressure medication.
Last year, I had my aortic valve replaced, and an angiogram showed about 30 percent blockage in my coronary arteries. This makes me believe a statin drug is a good preventative for artery blockages. Do you think that anyone with a family history of heart disease should get a calcium scan?
R.S.
A: A calcium scan is a special kind of X-ray that identifies calcium-containing plaque in heart arteries. It is not a direct look for blockages.
It’s possible to have a normal calcium score and still have blockages. Most blockages in the arteries are a combination of cholesterol plaque and calcium, but not all have calcium. Further, some people have calcifications with no blockages.
Doctors use specialized calculators that can help predict 10-year risk of a coronary event. If a person has high-enough risk to be on treatment anyway, a calcium score isn’t necessary to recommend treatment. A person with very low risk is unlikely to have coronary calcium, and even if they do, it might not mean blockages. For those who fall into the middle, the coronary calcium score provides additional useful information that can help a doctor decide whether medication therapy is appropriate.
The joint guideline from the
American Heart Association and American College of Cardiology recommends against the use of coronary calcium screening for people of otherwise low risk with a family history. The calculators do not take family history into account (there are other risk factors as well that are not in the calculators), so a doctor must exercise individual judgment. I have certainly ordered diagnostic testing in people who have low calculated risks but who have other risks not in the calculators (such as a patient of mine with a twin brother who needed a bypass).
A wise doctor doesn’t make decisions based on only one risk, whether it’s cholesterol or family history. The whole person — all their risk factors and protective factors, their ability to improve lifestyle, and their tolerance for medication — must be taken into account before making a truly personalized recommendation.
Q: I read about a 92-yearold man who said he followed an exercise program that needs only 10 minutes per day to maintain fitness. I would like to know where to find this program, since I need to get back into a fitness regimen at age 82, after knee surgery and arthroscopic procedures.
M.D.
A: There is evidence that high-intensity workouts of even short duration can have significant benefit for cardiovascular fitness. However, that is not the kind of exercise program I would recommend to a person who is recovering from surgery, which is a slow and gradual process.
Muscles, connective tissue and bone all get stronger slowly. It requires time to build them up, and trying to do a 10-minute high-intensity workout would be an extremely bad idea. A physical therapist can help design an exercise program that can help you recover from surgery and get you more fit. As you get more cardiovascularly fit, as well as stronger in muscle and connective tissue, you can certainly explore more high-intensity workouts.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Drive, Orlando, FL 32803.