Our shoulder is an amazing and complex joint and is likely underappreciated by most people. It is actually two joints that work together to make all of that miraculous motion happen: the glenohumeral joint, also called the true shoulder joint, where most of the motion (around 2/3rds) occurs; and the scapulothoracic joint, which is located between the shoulder blade and chest.
The "ball and socket" anatomy of the true shoulder joint is also unique in that, unlike the ball and socket of the hip joint, the socket is relatively shallow. As a result, the shoulder can achieve an incredible flexibility and range of motion that is found nowhere else in the body. Take a moment to appreciate all of the different activities the shoulder's unique design allows you to do!
However, the shoulder's complexity also makes it prone to injury, and perhaps the most common shoulder injury is to the rotator cuff. In fact, over 460,000 rotator cuff surgeries are performed each year, with rotator cuff repairs coming in as the second most common orthopedic soft tissue repair procedure performed in the United States.
The following is Toby Snow's story—his journey with the Door Orthopedic Center from acute rotator cuff injury, through to his recovery and eventual return to work.
"…as handy as a hammer in your hand…"
Last summer, Tobias "Toby" Snow, a general contractor from Door County, was working on a roof when his ladder slipped. He fell off the ladder, and when he landed, he landed on his elbow, jamming his shoulder.
"I need my shoulder," Toby says, "I'm constantly working overhead, constantly lifting something. In my line of work, your shoulder is one of your main tools. It's as handy as a hammer in your hand."
"I went to the emergency room that morning," Toby recalls, "because every time I tried to move my shoulder I passed out. I knew it was bad right away. After the accident," he continues, "I couldn't really do much of anything. I hurt my right arm—my dominant arm—so I couldn't hammer, I couldn't lift siding, I couldn't do anything overhead at all."
Three days later, Toby met with Dr. Mark Jordan, Orthopedic Surgeon at the Door Orthopedic Center.
"…a massive rotator cuff tear…"
"There were several red flags when he came to see me," Dr. Jordan recalls, adding, "Number 1, his shoulder was functioning well for him prior to his injury; number 2, he couldn't elevate his arm—if I lifted his arm up and let go, it would just drop right back down by his side; number 3, he couldn't externally rotate his arm. So, I had a very high suspicion that he had a massive rotator cuff tear."
The rotator cuff is comprised of 4 muscles—the supraspinatus, infraspinatus, subscapularis and teres minor—that begin at the scapula (shoulder blade), converge over the ball-shaped head of the humerus (upper arm bone) to form a "cuff," and attach to the head of the humerus with tendons. When one or more of those muscles or tendons tear, either through repetitive motion or acute injury, loss of motion, loss of strength, and pain are very common.
"I had an MRI to see how bad the tears were," Toby relates, "and it was the worst fear, that it was torn pretty badly—I had ripped tendons right off the bone."
Dr. Jordan adds, "The MRI showed that Toby had torn 2 major tendons, his supraspinatus and infraspinatus."
"…if I were in your shoes, I would choose surgery…"
"I believe it was June when I first saw Toby," recalls Dr. Jordan, "and one of the things that jumped out at that appointment was that he was a contractor and this was his busy season." Toby adds, "One of our first conversations was about how quickly I could return to work because I had people scheduled out—I needed to keep that schedule and keep my clients happy."
"He was rightfully concerned about having to take time off of work," Dr. Jordan remarks, adding, "It's certainly any patient's right to choose non-operative treatment, and I'm not in the business of talking people into surgery, but it's also important to let someone know what the long-term implications could be from an injury. In Toby's case," he continues, "we could see on his MRI that his humerus was sitting much higher than it should be, and that could lead to rotator cuff arthropathy—or arthritis. Additionally, with a massive rotator cuff tear, there is a bit of a ticking clock. If you don't get to it within 3 or 4 months, there are irreversible changes that happen to the muscle tissue—it atrophies and essentially it becomes unrepairable at that point."
Luckily, the MRI showed that there weren't irreversible changes to the muscle tissue and the rotator cuff looked to be potentially repairable. "I told Toby," Dr. Jordan says, "based on my experience treating this issue, if I were in your shoes, I would choose surgery. I would bite the bullet and get this thing fixed.'"
"…repaired…through a small incision…"
"Initially," Dr. Jordan relates, "the surgery involved a shoulder arthroscopy, or scope, so I could verify what the MRI showed. At that point, I made sure that I could move his tendon back to where it needed to go because if the tendon is retracted—if the tissue pulls into a new position—and you can't get it back to where it's supposed to go without an extreme amount of tension, the repair is not going to take—it won't heal. So, we confirmed that the repairs could be made without too much tension."
Dr. Jordan continues, "Toby's tear was big enough that I repaired it through a small incision as opposed to repairing it arthroscopically—it just allows me to get a better feel for these big tears where you need to pull the tendons back into place. Then," he adds, "we performed a biceps tenodesis, a procedure that is used when one of the heads of your biceps, which goes to your shoulder, becomes inflamed. Without this procedure the inflammation can act as a pain generator and often causes a struggle even after surgery. Toby's was clearly inflamed, so we just tacked that into a new spot as well."
Following his surgery, Toby began his rehabilitation program. "At first," Toby says, "the process was not moving. Obviously, you don't want to reinjure the rotator cuff, so it's more of a waiting game—about 6 weeks—just letting your body take over so it can do what it has to do to heal."
"Then there was a lot of stretching," Toby relates of his physical therapy process at the Door Orthopedic Center. "The muscles shrink and so the physical therapists spent a lot of time trying to get movement and strength back into the joint—the first 4 weeks of rehab were spent trying to get movement back in my shoulder," he adds. "And," Toby continues, "my physical therapist was in constant communication with Dr. Jordan, discussing what I could and could not do. Everything about how I was doing in therapy was relayed back to him. I think the fact that everybody communicated has a lot to do with my recovery."
"When I do a rotator cuff repair," Dr. Jordan adds, "there's a certain protocol that you follow after a procedure like that. And, our therapists know our protocols—they know the way we like things done. So, you don't get those phone calls of, 'Oh no, were we supposed to do this?' They know what our plan is—there's less chance of re-injury—so that's great."
"…I'm back going at 100%..."
Today, Toby has almost completely recovered from his rotator cuff injury. "Right now," he says, "I don't have any concerns about my shoulder at all. I think that my range of motion is better than we expected. I'm not lifting big, heavy, monster beams or anything like that—I don't push it—but I do almost everything else that I did before my injury. My strength is still not what it was, but it's coming back pretty quick."
Of his experience with Dr. Jordan, he adds, "He's a pretty good guy, and a great communicator. He explained everything—what was going to happen with the surgery and the recovery. And," Toby continues, "obviously, he has done this quite a few times—he knows how people are, and I'm one of those people—I don't listen, I usually push it. But, in this case I listened, and thanks to him, I'm back going at 100%."
"To a tee, Toby adhered to all of our recommendations," Dr. Jordan says, adding, "It really paid off. So, while he does lack a little endurance, he is now essentially back to his pre-injury level of function. From this point on," Dr. Jordan remarks, "we can continue to expect improvements even beyond a year. However," he cautions, "Toby's recovery is not typical. He has some factor that allows him to heal faster than most patients that I see—his recovery is not characteristic following a rotator cuff repair. But, with regard to where he is now, he is back to doing his normal job after 6 months—I couldn't ask for anything better than that."
"I would definitely recommend the Door Orthopedic Center to anyone," Toby says. "Because of my experience with them, I bounced back pretty quick. And, the people—the physical therapists, doctors, and nurses—everyone was great. I have no complaints whatsoever."
The Door Orthopedic Center at Door County Medical Center is a state-of-the-art facility paired with a top-notch orthopedic team that can get you back to daily living and your favorite activities as soon as possible. Our patients can expect exceptional outcomes—93% of our patients are discharged directly to their home, and The Door Orthopedic Center currently boasts a 100% overall satisfaction score.
To schedule an appointment at Door County Medical Center's Door Orthopedic Center, go to: https://www.dcmedical.org/medical-services/orthopedics/connect or call Door County Medical Center at 920-743-5566.