Shoulder1: When did you know you wanted to be a doctor?
Dr. Williams: Well, that’s a pretty easy question. Fortunately – or maybe unfortunately – I always participated in organized sports including football, basketball, and baseball, and for some reason I seemed to always be in the orthopedic surgeon’s office. I had a fairly severe ankle fracture when I was in high school, which cut short one of my football years and caused me to really think about whether I wanted to use brawn or brain as I chose a career. I had a predilection towards the sciences throughout my schooling. When the time arrived to choose a specialty in medicine, orthopedics was a natural fit. The field seemed to really require a natural understanding of basic science, injury mechanisms, and the technical expertise to fix the problems.
Shoulder1: So it was basically as a result of being on the other side of that doctor-patient relationship that you decided to go into sports medicine?
Dr. Williams: Exactly. I always found orthopedic doctors to be very happy, positive, upbeat individuals. As I mentioned, I was always interacting with them, and as a result, sports medicine became a very exciting career choice as I completed my medical training. I love the problems, the patients and the surgery. It is a very satisfying profession.
Shoulder1: Could you describe where your current clinical and research interests lie?
Dr. Williams: My clinical and research focus all stem from my training. I did all of my training in orthopedic surgery at the Hospital for Special Surgery in NYC. After my residency, I took a fellowship in sports medicine and shoulder surgery. So my practice specialty is primarily comprised of knee, shoulder, and elbow problems in an athletic population. I have a fairly dynamic group of patients who prioritize athletics as an important part of their lives. There’s no specific age group, it’s really more focused towards people who are active and desire to continue to be active.
I became particularly interested in shoulder problems while serving as the Associate Team Physician for the NY Mets baseball club. It was really then that I started to look critically at some of the surgical procedures and problems that were unique to this group of individuals, namely the throwing athletes. So I’ve concentrated my clinical practice and research on the shoulder while trying to better understand the problems that these athletes encounter, such as shoulder instability, rotator cuff disorders, and labral tears.
I’ve done research in a couple of main areas. I have done a lot of work here at Special Surgery with a number of my colleagues using electromyography (EMG) and digitized motion analysis to assess throwing athletes, namely football quarterbacks and pitchers. We felt that if we better understood the mechanics of these throwing motions, we might better understand the mechanisms by which these athletes are injured.
Shoulder1: Can you tell us a little bit about how those technologies work?
Dr. Williams: Basically what we’ve tried to do is utilize some of the modern computer software that’s available in motion analysis to analyze specific throwing motions. We have also analyzed upper extremity motion in persons with rotator cuff disease. In these cases, we isolate certain muscles that might be responsible for shoulder dysfunction (i.e. the muscle attached to a torn rotator cuff tendon), and use the EMG to see how this muscles is firing.
We are also able to analyze using video analysis how these individuals perform certain tasks in the presence of a torn rotator cuff tendon. We are then able to integrate the muscle activity data and correlate these finding with the motion analysis.
This process may ultimately aid clinicians in determining why someone might need surgery for a particular problem as opposed to a course of physical therapy. We bring people into the motion lab and set up a high speed video analysis, with markers on the upper extremities of the body, and also coordinate that with EMG tracings which show muscle activity. So we’re able to get a pretty through assessment of, say, a quarterback throwing a pass, a pitcher throwing a pitch.
Shoulder1: It sounds like one of the advantages of that is that you can see people moving as they really would, rather than being immobilized or undergoing a more invasive procedure?
Dr. Williams: Yes, for the most part it is a non-invasive test, and the biggest difference – versus an MRI, for example – is that it is dynamic; you can see the patient moving and trying to do a functional test. Now we’re getting to patients with rotator cuff injuries. We’ve done a lot of work with them in the past few years, having them do things like lift a small weight, put their hands behind their back, put their arms behind their head, things that they would do in the course of normal daily activity where maybe they’re having some trouble.
Then we can compare their attempts at these tasks to those of a population of normal individuals that we already have in a database. That’s been really helpful. We actually won – that is, a group of my colleagues and I – the Charles Neer Award from the Society of American Shoulder and Elbow Surgeons for work done using those methodologies specifically for rotator cuff problems.
Shoulder1: Speaking of accomplishments, what do you feel is your greatest contribution to the field of orthopedics and orthopedic surgery?
Dr. Williams: Well, I think currently one of my greatest contributions is trying to be a bridge between understanding clinical problems and trying to develop basic research that is directly relevant to solving those problems. I think the work we’ve been able to accomplish, specifically with the use of motion analysis and EMG, and its role in helping us identify one of the rotator cuff muscles that’s particularly important in determining if someone is going to successfully rehabilitate from a rotator cuff tear. It’s been a really big – really big – positive finding from my side of things. It was an unknown fact before our study.
Just to summarize briefly, there are four rotator cuff muscles. In patients that have a symptomatic rotator cuff tear, if the subscapularis muscle was actively firing at a near normal level, those are the individuals who despite having a rotator cuff tear in the other muscles usually were able to do quite well with efforts at rehab. In contrast, those folks who did not have an adequately compensated or adequately firing subscapularis muscle, typically did not do well despite attempts with a physical therapist, and those patients typically went on to need surgery.
Shoulder1: It sounds like those research results really shrunk the aperture on the range of what could be wrong and the range of what was likely to happen.
Dr. Williams: Right. Because part of the problem was that patients would come in with rotator cuff injuries, acute injuries, and it would be very difficult for us as doctors to predict if they’re going to need surgery or not. And most folks, if you tell them, "Listen, you can do this physical therapy for six weeks but ultimately we believe, based on what we’ve found you’re going to need surgery," a lot of them are probably going to opt to have surgery right away.
Shoulder1: So you can eliminate the waiting time and get people going on post-op rehab sooner?
Dr. Williams: Exactly. And though we haven’t been able to fully integrate EMG analysis into clinical practice, it has become a big focus for us here at the hospital to make that more available to the general public as a diagnostic tool.
Shoulder1: You are also an Assistant Professor in the Department of Orthopedic Surgery. How would you say that your role as an educator has effected your role as a researcher and practitioner?
Dr. Williams: Well, we are an academic institution; we’re affiliated Weill Cornell Medical College and the New York Presbyterian Hospital, and one of my roles here is to actively participate in the education of fellows, residents and medical students. The fact that we do a lot of basic research, not only in the shoulder but also in the knee, means we typically are sought out by people who are currently going through the training process. For me it has become a big part of why I am active and interested in that arena.
Shoulder1: One thing that we’ve been hearing about from various doctors is the role of the dialogue in a teaching or university-affiliated situation. How would you say that effects you?
Dr. Williams: Well, we really do have a rich environment here in that regard. Essentially, I have fifteen colleagues, who are, like me, very involved in the academic process – locally here at the hospital and medical school and nationally – so we have a very rich exchange of ideas that occurs constantly. This exchange is something that I benefited from on day-to-day basis. But more importantly, my patients benefit from it because it’s not just my experience they’re getting, it’s a whole collective experience here at the Hospital for Special Surgery that forces us to be very analytical, very critical of what we’re doing as surgeons. Our exchange also ensures that our patients are being offered the very best in current surgical care.
Shoulder1: Looking ahead, what changes do you hope to see in your specialty in the next five to ten years?
Dr. Williams: I think the most exciting thing about our specialty is the use of minimally invasive techniques to correct the shoulder problems that we typically face. Repairing rotator cuff tears, stabilizing damaged ligaments in shoulders that are unstable or dislocate, repairing labrum lesions or dealing with bone spurs: these are all procedures that have evolved over the past twenty-five to thirty years.
Recently our specialty has made great strides in the use of arthroscopic techniques in the correction of these problems, and our research is validating these methods. At HSS, we currently have two prospective studies that were designed to specifically investigate two of these problems, rotator cuff and stabilization injuries. Our preliminary analysis is demonstrating that our arthroscopic procedures are just as effective and much less painful than the previously described open procedures, what would be known as the gold standard surgeries. This is very exciting because it allows us to tell patients with confidence, not only can we do it through the scope or do it with one or two incisions around the shoulder, but that a successful outcome is expected. Our research that has been done in a very systematic and painstaking manner has validated that: "Yes Mr. or Ms. Patient, you can do this and be confident that not only is it not going to hurt you as much and your rehabilitation going to be shorter, but also your shoulder is going to work well in the long term." It makes my job easier.
Shoulder1: Do you have any final thoughts on the future of sports medicine for our readers?
Dr. Williams: Well, to give a sense about where sports medicine and minimally invasive surgery are going for me, my approach is to empower patients’ decision-making through information. I encourage people to learn as much as they can about what they perceive to be their issue before coming in to meet their physician. Then we can have a really high-level discussion about the nature of the problem, its severity, and the consequences of treatment, surgical or otherwise. I prefer patients to be well educated about their problem, so that they can go home and consider questions like: "For me to play tennis I need to do blank, or for me to do my work I need to do blank." Most of my procedures are elective, and patient must ultimately decide whether or not to go forward. If a patient is informed he or she can say, "Hey listen, I need to work, and without this surgery for my shoulder I will probably not be able to work, so yes, I think it’s worth it for me to do this."
From the surgeon’s side, we’re feeling almost giddy at the prospect of helping these patients, with relatively low morbidity, less pain and quicker recoveries. It just makes the decision-making process from our side that much easier. We’re really not looking at any huge down sides to the surgery option, so we can say to patients, "Think about it, and we’re happy to help you out if you think the operative way to go is appropriate."
Hospital for Special Surgery