By Tom Keppeler, Shoulder1 Staff
Dr. Peter Simonian is the Chief of Sports Medicine Clinic, as well as the Director of Sports Medicine Research and an Associate Professor of Orthopedic Surgery at the University of Washington (U of W) School of Medicine. He also currently serves as the Team Physician for the U of W Husky Intercollegiate Athletics Department, and has performed a similar role with the New York Mets in the past and is a Consultant to the Seattle Seahawks. His research has resulted in numerous publications in most prestigious American and international journals. Dr. Simonian is also the recipient of multiple awards.
You can read a chapter on Shoulder Injuries in Dr. Simonian's upcoming book here.
Knee1: How did you develop an interest in shoulders?
Dr. Simonian: It developed primarily from my great interest in sports medicine, and taking care of injured athletes of all levels. The two most common orthopedic injuries in athletes are to the knee and the shoulder. We have a lot of good solutions for knee problems, and I think we have lagged a little bit in our ability to effectively treat shoulder problems until the recent decade. Now, especially with arthroscopic techniques, we have a much better understanding of the anatomical variations of the shoulder and some of the pathologies that we were unable to recognize prior to the advent of the arthroscope and better imaging techniques.
Knee1: What makes the shoulder so complex?
Dr. Simonian: The primary complexity of the shoulder is that it has an incredible range of motion compared to other joints in the body. In contrast to the knee, which essentially moves in one plane through flexion and extension, the shoulder moves through several planes including flexion and extension, internal and external rotation, abduction, and adduction. For these complex motions to occur, the bony constraints of the shoulder joint have to be small, meaning the socket and the ball are not firmly attached to one another. [University of Washington Orthopedic Department Chair] Dr. Frederick Matsen III, who is a world-class shoulder surgeon, has made the analogy of thinking of the shoulder joint as a golf tee with a golf ball sitting on top of it, meaning that the stability afforded by the bony structures is minimal—the rest comes from soft tissue restraints in the shoulder. There are static restraints, those are the ligaments, the capsule and labrum, which can be damaged with shoulder injury. Then, there are the dynamic shoulder restraints—these are things like the rotator cuff muscles, which can also be injured. Together, these static and dynamic constraints, as well as the bony constraints, provide a delicate balance of stability to a joint that has an incredible freedom in its motion.
Knee1: What makes the shoulder so susceptible to injury—is it because there are so many parts within the joint, or are we as humans doing tasks we weren’t designed to do?
Dr. Simonian: There is a component of both factors. For example, in the overhead athlete, chronic overuse results in many injuries. The shoulder, like any other joint, can only take so much—it is a beautifully designed joint, but like any of our joints, if you overuse it, it will start to break down with time. Then, there are the acute injuries. The most common acute injuries involve dislocations, fractures and rotator cuff tears. It is the complex shoulder anatomy that allows a delicate balance of extreme range of motion while maintaining stability; when combined with repetitive or traumatic sporting or job activities, this balance can be compromised resulting in injury.
Knee1: Who is at the greatest risk of a shoulder injury? Obviously, overhead athletes are at great risk, but there are certain occupations that pose a great risk of injury as well, right?
Dr. Simonian: There are two basic groups of people that have a higher risk of shoulder injury. The first are those caused by chronic over-use resulting in problems like tendonitis, bursitis or impingement. There is another group whose injuries are the result of acute traumatic injury to their shoulder.
Knee1: What are some of the best things people can do to prevent injury to the joint?
Dr. Simonian: Let’s look at those two groups of people again. For the type who is involved in repetitive activities that utilize the shoulder, there are some very basic rehabilitation techniques with rotator cuff strengthening that can help and serve them well. Most of these exercises are very basic and easy involving internal and external rotation movements. These differ from the type of exercises one would do at an athletic club, and most weight equipment at the gym is not designed to work the rotator cuff. For the group suffering from acute traumatic dislocation, this injury can happen to anyone, regardless of the shape of their shoulder or the rest of their body, and it’s just a circumstantial event or accident.
Knee1: What specifically has happened with arthroscopic surgery in the shoulder in the past decade?
Dr. Simonian: Orthopedic surgeons sought a less-invasive method of treatment of shoulder injuries. There can be significant morbidity associated with standard open surgical techniques. For a surgeon to access the shoulder joint through conventional open surgery, one often has to surgically violate intact structures. With the arthroscope, you can avoid this damage altogether. Arthroscopic treatment has led to improved outcomes, decreased pain, and faster rehabilitation for certain conditions affecting the shoulder.
Knee1: What are some of the more interesting developments in shoulder care that have developed over the last few years? Are there any new methods that surgeons are trying out?
Dr. Simonian: There are two areas where recent progress in shoulder surgery has been made. The first is in shoulder-stabilization procedures for instability, followed by rotator cuff surgery. I think that with both, the changes have come from new techniques that involve arthroscopic, rather than open, treatment.
Another topic that’s received a lot of press and a lot of interest are some of these thermal tissue manipulation techniques used to arthroscopically stabilize the shoulder. The results of these techniques are preliminary and we still need longer follow-up to determine the effectiveness. This technique has been an exciting area with a lot of interest and healthy debate.
Rotator cuff surgery has also improved through the introduction of new fixation devices that allow repair in an arthroscopic and less invasive fashion compared to conventional open surgery.
Knee1: What do you see as your role in these developments?
Dr. Simonian: I am in a fortunate position, because I have a very large patient referral population with significant shoulder problems and also have all the resources to perform cutting-edge research at the University of Washington. This combination provides a unique advantage for development and improvement of current shoulder procedures.
Knee1: So, you deal primarily with athletes?
Dr. Simonian: Athletes comprise a large percentage of my practice. However, many of my patients are not athletes and have shoulder problems resulting from acute traumatic injuries or chronic injuries that have not improved with conservative treatments.
Knee1: What percentage of your patients are athletes?
Dr. Simonian: It depends on how you define athlete. Most people who come into my office consider themselves recreational athletes, so, if you take that into account, I would say about 70 percent of my patients are athletes of some type. The group of elite athletes is actually very small, more like 5 percent.
Knee1: You’ve worked with the University of Washington Huskies and the New York Mets as team physician—any interesting stories along the way from those experiences?
Dr. Simonian: There have been plenty. With our athletes, primarily at the University of Washington, shoulder problems are a major issue. Shoulder injuries are common in our contact athletes, like our football players. I operated arthroscopically on two of them in the off-season and both are having a wonderful early season this year. The team is currently ranked in the top 10 in the country and both of the guys are starting, and it’s terrific to see them out there without any shoulder complaints.
Our overhead athletes—baseball players, tennis players, and swimmers—comprise another group shoulder issues. This is a difficult group because many of these injuries represent chronic overuse; much of the treatment for them is primarily based on rehabilitation and good mechanics. Often, you can beat the problem with a good, solid rehabilitation program, but it takes a lot of patience and dedication to get through it.
Knee1: You have written a textbook chapter on shoulders, where you mention that tendon tears within the shoulder are increasingly fixed arthroscopically as opposed to open-shoulder surgery. What made this possible?
Dr. Simonian: When you’re speaking of tendon tears around the shoulder, they are most often rotator cuff tears. If you surveyed a group of orthopedic surgeons, probably more are still doing these repair techniques in an open fashion, or arthroscopically-assisted. There are several ways to perform the surgery. There’s the conventional, open technique, but the problem with that is that you end up taking down a portion of the deltoid muscle from its attachment to the acromion—that can involve increased pain, delayed and prolonged rehabilitation. There’s a relatively new technique of arthroscopically-assisted rotator cuff surgery, called the “mini-open” repair, where much of the procedure is performed arthroscopically. Many surgeons are using this technique.
Then there is a group of surgeons using an all-arthroscopic technique. I think what’s made this viable are, better repair techniques, better arthroscopic instrumentation, and better fixation devices. This technique may decrease morbidity even further.
Knee1: You also mention a number of factors in your chapter to consider when weighing surgery against letting the injury heal on its own. What are some of them?
Dr. Simonian: It really depends on the specific injury to the shoulder joint. I think we can discuss two that most often result in this division between surgery and conservative treatment. One is acute shoulder instability or shoulder dislocation. In talking about that, one of the most important factors is to understand the age of the patient and the activity level of the patient. For example, the most important factor in recurrent shoulder dislocation is the age that the first dislocation occurred. So, if your first dislocation occurred when you were 17 years old, there is an extremely high probability that you are going to re-dislocate it. If your first dislocation happens when you’re 35 years old, there’s a very high chance that you will never dislocate it again, regardless of what you do—surgery or no surgery.
It also depends on the type of athletic activities you perform. There is a group of people who are going to continue to subject themselves to the kind of activity that caused the first dislocation, whether it’s contact sports or a job or something else. Those are the type of people who need to consider surgical stabilization, because after you have one shoulder dislocation, the chance of a second, a third and a fourth is progressively higher, because the tissues get progressively stretched out. Sometimes, you get small bony fractures of the socket called a Bankart Lesion, or a divot in the back of the humeral head called the Hill-Sachs Defect; these things can make you more susceptible to recurrent dislocation. But, if it was a freak accident, if the patient is a little bit older and not quite as active anymore, rehabilitation and non-operative treatment are definitely the first line of treatment. Some people would advocate that for all dislocaters, but many surgeons are coming around and starting to think that if it’s a young athlete, who is continuing to subject himself to these high-risk activities, primary surgical stabilization, even with arthroscopic techniques, is probably a good alternative.
Another dilemma is rotator cuff tears—whether you should treat it surgically or conservatively. In rotator cuff tears, you can simplify it into two groups. The first are the younger patients, under the age of 50, who have had a traumatic rotator cuff tear—either they have a fall or some kind of sudden force to their arm that tears the rotator cuff. In that group, early surgical repair will maximize function. There are also the elderly patients who have rotator cuff tears that may have come on in a more chronic or progressive manner, with slow degeneration of the tissue. In this group, the right treatment is to consider rehabilitation first, and to see if, by strengthening the remaining rotator cuff muscles that are intact, it improves strength, range of motion, and even decreases the pain associated with the tear. If that does not work, surgery is certainly an option. Now, again, these algorithms represent generalizations. No two people are the same, no two circumstances are the same, so the right answer is very individualized to the specific patient.
Knee1: Lastly, where do you see orthopedic surgery for the shoulder going in the next few years? Where do you see big developments?
Dr. Simonian: The shoulder is one of the most exciting areas of orthopedic surgery. The potential for new ideas and new developments in treatment methodology is very promising. The advances in shoulder surgery in the last 10 years have been one of the greatest, and the future holds many advances to better serve our patients.