The Sports Physical Therapy Podcast
The Sports Physical Therapy Podcast
Rotator Cuff Repair with Amee Seitz - Episode 26
Rotator cuff repairs may be one of the more common surgeries in orthopedic and sports physical therapy settings. Yet, there seems to be absolutely no consensus on what postoperative guidelines we should follow.
On this episode, I’m joined by Amee Seitz from Northwestern University to discuss some of what we know about how fast or slow we should go after rotator cuff repair.
Full Show Notes: https://mikereinold.com/rotator-cuff-repair-with-amee-seitz/
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On this episode of the sports physical therapy podcast, I'm joined by Amy sites. Amy is an associate professor at Northwestern university and the physical therapy and human movement science department, where she focuses on musculoskeletal shoulder injuries in her clinical practice and research projects. In this episode, we're going to talk about rotator cuff repairs and the lack of consensus on postoperative rehabilitation guidelines.
Mike:Amy, thanks so much for joining us on the podcast today. How's everything going?
Amee:Great. Thanks Mike for the invites. Pleasure to be.
Mike:That's awesome. Well, I mean, before we dig in, um, I feel like you're just always up to so much. Um, and I know I'm gonna ask you this at the end a little bit here too, but, uh, what are you up to? Uh, now we're, we're Northwestern, right? We're over in the great city of Chicago. Right? Tell me a little bit about your.
Amee:Yeah, so I'm, uh, I'm, uh, on faculty at Northwestern in the physical therapy human Movement Sciences, uh, department. Uh, we have a large program. I mentor, uh, PhD students. And, uh, Bioengineering, um, kind of post-professional degree. And then, um, you know, we have a residency and fellowship. I have a little bit of mentoring in that. Very little, uh, more on the didactic side of that. And, you know, just trying to keep my head above water writing, uh, CPGs and
Mike:Oh, CPG seemed like so, so fun to write
Amee:they're great when they're done.
Mike:Exactly. Well, um, any good person from Chicago, I gotta ask, are you a south side kind of gal or you wrigleyville, Like what do you,
Amee:Oh, are you're gonna make make me commit? Well,
Mike:White Sox or Cubs. What do you got?
Amee:So, you know, I was from Boston. I moved from Boston, uh, to Chicago in 2014, and so Theo beat me by a couple years. So, you know, I say that I was the, the trifecta that made it happen in, in Chicago because, you know, they had Theo, they had Lester and they brought me Chicago and now, you know, made it happen. But you know, the white sos are come, you know, I, I have, have a lot of hope for them. They have a good trajectory and I just think it was just a little bit of a struggle here. Maybe
Mike:Next year's gonna be good. I'm optimistic. We'll see. We'll see. I'm, uh, I'm optimistic. We'll get there, but All right then. Real cool. Real.
Amee:I hear they have a great upper extremity kind of consultant,
Mike:We have, we have a very good medical performance department. We're working on it. But, um, Alright, so real question here is people are gonna already cancel this, this, uh, episode and they're gonna move on to the next one, but, alright, so what's cool at Wrigley or Fenway then?
Amee:Ooh. I am a fan of the older stadiums, right? So, I think for me it would be, I don't know. I, I, I do like Fenway. I hate to say it, It, it is, it's a, it's a great, great, uh, uh, field and like, just to the environment there, it's so old school. You got, you know, poles in the way when you sit, have time, but, uh, just, just feel so closed. You know, WR is a good number two, I love the like,
Mike:Yeah, The Ivy's cool. Yeah. I, I, I don't, I, you can't go wrong with either. They're both pretty special. But anyway, we're supposed to talk shoulder stuff. I think that's more importantly. So, um, it's been awesome to watch your career. I mean, I think. We first met like 20 years ago, and, um, really watching you evolve your research and it's almost like, you know, just getting to know you a little bit. Like back in the day, um, I always, I saw that like critical component in your mind. I remember having some good conversations with you and, and I always saw that. And it's funny, like when, when I look at all your publications, I, you can almost, it, it, it tells a story, right? I can actually see what was evolving in your head and, um, kind of all your research projects over time really tell a story. So I thought that was really neat. You've spent a ton of work on the shoulder. I wanna talk a little bit about rotator cuff today with you. Um, let's start with this, and I think this is a big question right now. Shoulder impingement. This has really been challenged and I like using that word because, because that's a, that's a popular word on social media now. We challenged things, but it's been challenged recently regarding its validity as a diagnosis. Right. Um, I'm just curious what your thoughts are on children impingement on this terminology and how you've evolved your thoughts over your career on this. Cause I know you've put a lot of work into this.
Amee:I think there's, you know, there's always the scientist that says, Well, we don't really understand which structure is implicated with, with regards to pain provocation tests. So all the, all the rotator cuff tests, or at least those that aren't like large, massive full thickness tear tests, tend to be tendon resistance tests, uh, and provocative positions that reproduce pain. And so, you know, I can appreciate the fact that we don't really know what structure is implicated when you have a pathology, meaning a. and you got positive, painful tests. Um, you know, the gold standard for ruling in historically, um, uh, ruling in and ruling out, coming up with the diagnostic accuracy of these tests is really based off of finding the pathology. But so many times now, and, and it's been repeated throughout the body in different regions, you know, there's a lot of asymptomatic pathology. Um, and so you can't always implicate the pathology as being the painful source, so I can appreciate that. I think it's very academic. I think, you know, impingement certainly from a standpoint of structures being pinched, that's a different, uh, kind of mechanism to me than, than the term impingement. Meaning let's just give it a diagnosis that's a cuff related to something. I don't really care what we call. I think, um, I think we have learned a lot on how prevalent internal impingement is compared to like what we used to think extrinsic impingement or burse side impingement, and that was the model that I grew up with. Teaching patients like, Oh, you raise your arm up, you pinch the tendon on the, on the acro. And you know, we just need to get things moving a little bit better, scapular mechanics and better, uh, glen of humeral motion. But we should be good to go. And I, I can't say that that that story is probably, is, is much different except for the fact that we probably now better know that pain below maybe 70 degrees of elevation is really a feasible range for impingement, uh, in the, or under the acromium. And then as you elevate the arm, 130 to 140 degrees. We start to get in the range where you get internal impingement, which is the underside of the cuff, which we historically thought was only in throwers in that late caulking position, but it's not right. It can happen just with arm elevation, whether that be abduction or flexion or scaption. So I think, you know, those are really cool. It's cool. Mechanistic kind of given us some insight into things, but when it comes to the bottom line of treat, You know, maybe we need to think about how much that's really changing as a physical therapist, what we do, and I'm not sure we're there.
Mike:Exactly right. Cause you, you're probably still gonna do the same thing anyway, which makes sense. But, um, I, I think the narrative that I'm seeing quite a bit is that, you know, impingement is normal. We all impinge every time we move our arm, like we impinge the structures. And of course we've, we've known that for decades. That's actually not new. Um, and I, I think sometimes it's too simplistic when people say like, Well, if you impinge. All the time that impingement isn't valid and an impingement isn't a concern and it may not cause issues in the future. And then we reference like a systematic review of, uh, you know, 200 people age 18 to 75 with, uh, a various amount of shoulder pain. And they're like, Look, nothing, nothing's valid. Right? So, uh, it's just very, I, I think it's been oversimplified and I, I feel bad for the early career professionals that are trying to, trying to, to wrestle with that, right. That concept in there and learn all that.
Amee:Yeah, I think, you know, people have asked. Particularly seasoned clinicians. Are you still teaching special tests in the entry level program? And Yes, of course I am. I mean, we have a,
Mike:of course.
Amee:We try to communicate with other professionals, and if we don't teach those, it's gonna be very challenging to communicate with orthopedists. And I think it's important that we have some data that shows us what a prognosis might be with particular interventions. And right now using a cluster of examination findings that help us rule in, but I don't care how you label it. Some diagnosis gives us some papers. We have a good sense of what we should what, what's evidence based, what we might wanna try in this patient. And of course there's always individual factors, but certainly starting with things that we know are effective is not a bad place to start.
Mike:Right. I think that's a good way of saying it too. And, and, and I'm, I'm still in the boat of, you know, special tests have value obviously is, you know, we're trying to determine the sensitive tissue or whatever it may be, or provocative motion, um, you know, that should help align your treatment plan. Um, Right. And, and I, I, I can't imagine how it wouldn't, but, um, but I get, I get it.
Amee:Well, one thing that I think was underappreciated, and I completely underappreciated this, was the fact that you could have no castic pain, and so you have somebody that has a different pain presentation and a pain mechanism. Sure. For those no deceptive pains, yes, we can implicate a tissue, but it's that other group. That we might have ignored and not, and try to do the same test. And they have this cluster of examination findings. So now we have a muddy base or population that we studied. Might not be all this nociceptive. This is the pathology that's causing the problem. We might have a mixed bag. So I'm excited to see what's gonna happen in the next couple, you know, five to 10 years with regards to outcomes research. Cause we have a different game now we have a way to define patient's pain presentation that may not have been uh, so great historically with the trials that currently exist.
Mike:I love that. That's a great point. And, and it will be, it will be nice to see how that evolves. I think that's, that's pretty neat. Um, let's talk about cuff repairs, cuz I think this, this is a big topic I wanted to talk to you about. Um, I, I still think it's absolutely amazing to me, and this is something that I talk to people all the time online, the dme, I got people in my, my mentorship group that like ask me this question all the time about rotator cuff repairs. But, um, it's one of the most common things that we. Right. Like I think in orthopedics, even sports, we see rotator cuff repairs all the time. Yet there is almost no consensus at all on how to manage these after surgery. No, no consensus on the direction, the protocol, what to do. And you see everything from start early range of motion and, and some people that don't start PT for three months. Right. And then, you know, I had somebody just the other day and my mentorship group was asking me, you know, about rotator cuff protocols and he said their, their doctor just has one protocol. And I'm like, wow, like one rotator cuff, probably like every tear is the same no matter what muscle, what size, what tissue quality, what age, what mechanism. It's all the same. It was crazy. Um, I, I think this is crazy. Um, you published a nice little paper in, uh, the journal, Shoulder Elbow surgery recently where you surveyed a group of PTs and docs about these protocols. What did you find, and I can't wait to hear this because, you know, obviously I've read the paper, but what, what, what did you find and what were you most surprised about from this?
Amee:Yeah, I guess one thing, First of all, this was a group that was out of Philly that, uh, had reached out to me and was asking me to participate, and so I asked a couple more questions and, and next thing you know, I'm, I'm involved in, in trying to be part of the research team.
Mike:I love
Amee:I think, you know, I have a lot of respect for Dr. Abu and Liam Kane and some of the other, uh, physicians that were on that paper. But I think, you know, the perspective of the PT probably and the term terms that may have been used weren't probably, uh, uh, things that we are maybe familiar with. We don't, we don't understand. Acuity has a lot of different. Name, You know, uh, I guess, uh, uh, definitions in the PT world, right, is acute meaning, uh, it just happened, or is acute, meaning it's severe and pain severity. So I think, you know, that's one thing that if I could have done differently with that, with that survey, I would've, but interestingly, I think the questions were phrased well enough. Um, the scenario was put forward where a patient is presenting with a full thickness. Superos and infr spino tear. So for me that means it's at least two centimeters, maybe three. It's a pretty big tear. Um, and so you say, Okay, the first question that was probably most remarkable and the differences in PTs versus Orthopeds was, you know, when do we start passive exercises? And you brought this up, um, you know, PTs are like, Yeah, we can move these things. We can move these things within, you know, three weeks. So the question was, can you start'em before three weeks? Well, sure. I think, you know, the majority of PTs, like 80% of PTs said Yes, we can do this. And I think we have a better appreciation of the literature with regards to EMG data, how much tension is maybe put on the repair in these various positions, that we are less worried about it than maybe some of the physicians. Uh, and I think if some of, and so the physicians, certainly you had, they were split, had, you know, 30% that. I don't really care. It's not one way or the other. Then 30% said agree and 30% said disagree. And so, you know, I think they take into account they're the ones that are really worried about the repair integrity. Um, we are worried about that, but we're also worried about the other impairments and trying to restore normal function. And not to say that they are not in any way, but their key objective is for that repair. The thing that they spent the most time doing to kind of holds. Our key, you know, outcome is if the patient has full function and returned to prior level of activity and feels good. So I think, you know, we, we might have a better appreciation of the EM EMG literature, um, and that's that, that could be why I personally think. I mean, we're based off EMG studies, 10 superos. There's very little activation. If you can get someone to relax, I think the situ situation, you could do things like, um, walkouts, putting your table, walk your rear end out. You can do, uh, things like active a system, even just supine, active forward punches. That's less EMG activity than a, than a pendulum. And the physicians usually give the patient's pendulum so,
Mike:right.
Amee:A matter of like what the comfort level of the physician is and their repair. I can appreciate the fact they might be more concerned, but certainly I don't feel like we can do a lot of damage with that. I think the other key objective, like or the key difference that we noted with that study was when to start active exercises. And so similarly we have a scenario that same scenario, patient scenario, and a lot of the physicians said they would, you know, they disagree. That's, uh, active ra, you know, when, when do they think active range of motion, uh, exercises should begin? And they're thinking more around the six, six week mark, um, and physical therapists from around four to five weeks. So I think, you know, we, we, we might be a little bit, uh, more comfortable with, uh, the stresses that can be imparted through there. I think one thing that we might not always know, and we probably should do a better job, Is getting a report from the physicians that say, Here's what the tissue quality was, here's what the terror size configuration was, here's where, uh, you know, this is how many anchors. This is what I did for the, uh, for my surgery that may be unique. What was the muscle integrity like with regards to fat infiltration and atrophy? I think all those things, if it came in a little summary, I would fully have a better idea of the best way to rehab this person than if it was just, All right. Don't, don't move them for six weeks and we'll just cross and help things Hold up.
Mike:Yeah. Right. That's, that's never a good approach in my mind is to just cross your fingers as a physical therapist. Right. We don't like that. But, um, yeah, I mean, you mentioned the EMG studies and I, I think it's funny you compared, you know, some things like pass range of motion. Even some of our basic exercises are. Like a pendulum or even like some of the active assisted range emotion that the doctors love, right? Like, yeah. Do rope and pulley. Like, well, that actually has more EMG than some of the things that you're not letting us do, Right? Uh, but the thing that blew my mind, if you actually look into some of the functional tasks, uh, research, is you could do things like opening a door or brushing your teeth or just normal things around the house has more EMG activity than some of the things the doctors are sometimes worried about.
Amee:And I, and not in this survey, but as an, as an, as a as an aside, you know, there are two randomized trials that came out in the last couple years that talk about no sling versus sling in patients with rotator cuff tears. And both of those studies show, you know, one outta Switzerland and uh, one outta of Canada. Show that there were no difference in retail rates, uh, between those that, um, didn't wear a sling. Now, some of the caveats that I think it's important to make sure that we understand with that is the one that I said, Okay, you could come out of the sling for comfort. You can do things that are pain free. I don't want you to do active ab. Right. Um, thing you shouldn't be lifting things less than, less than a pound. And so they're, they're giving them some general guidelines. They're not just letting them have at it. Um, but you know, there's really no differences from a standpoint of, uh, repair integrity. The good news was from a range of motion perspective, from a pain perspective. There's, you know, you get better outcomes if you start moving earlier. So the earlier result results, you know, at 4, 6, 3 months, um, show that you have better range of motion. So I think, you know, I think the one study did, didn't limit the tear sizes. They had a ret tear, uh, rate somewhere around 20. 30 or something like that. The other study limited it to small to medium tear sizes and they had only two retailers of the whole cohort and I think it was a 60 or 80 subject. So I think from that perspective, you know, the larger, the tear size, we might need to be a little bit more cautious about letting them actively move straight away and not using the sling, but certainly with those that are small and medium. Size rotator cuff with good tissue quality? I guess I wouldn't, wouldn't worry so much. I guess the biggest question is what athletes are, have a rotator cuff pair now, which are these athletes.
Mike:Right, Right, right. Well, not anymore They're, they're, they're about to be unprofessional. They're about to It's, it's, it's hard to, it's hard to get back.
Amee:So these are like your kinda weekend warriors. These are like your 40, 50 year olds that, you know, may have had some 10 changes. Anyway. So I think that's the other thing that really is kinda remarkable just to see in, you know, in, in, you know, more professional athletics. Just the, the changes in what you've seen from a standpoint of pathology like,
Mike:Right. I, I've even noticed with my rotator cuff repairs in general that, um, you know, 20, 25 years ago or so, I mean, it was a, it was very much an older population and I don't wanna say fairly isolated cause that's not fair, but, I would say the, the mean demographic that we would see would be a little bit older Nowadays we're, we're either jumping on these a little bit sooner, or maybe we're just doing more through our lifespans, but I feel like the mean age of rotator cuff repairs is coming down a little bit. And you know, I, I wish the protocols and the surgeon preferences would kind of match a little bit, because I think you're right. I mean, tissue quality age, um, the size of the tin, there are so many things that go. Go into determining what's the, the safest approach after surgery. And I feel like just sometimes the docs just, they just blindly wanna be conservative because they're so worried about failure on, on examination down the road and the integrity of the repair.
Amee:I agree with you. I agree with you, and I think you know. You know, some, some of the protocols that may be a bit more aggressive. I have no problem with partial thickness tears for me. I don't feel like that's a big concern that this is gonna be a re-rupture. I think the other thing is like a small rotator cuff repair and an athlete that typically you could have rehabbed, might, might, might do, okay with a more accelerated program. did it really matter?
Mike:Right. Yeah, Yeah, yeah. It's, I I, I just, I find it interesting and, you know, I mean, I understand the physician's perspective. I mean, if you look at the, the, the results, you look at the research, there are a large amount of retails. And the structural integrity of these repairs, uh, aren't great. But again, if you, if you dig in deep, it's the older patient with the bigger tear, with the worst tissue quality. Um, and those people have different goals, They have different objectives, and our rehab progression should match that and should match their expectations. Right. Versus a younger person. Um, you know, so I, I'm not sure your experience with, with, you know, some of the physicians you work with or some that you've researched here, but. Do you think we're paying enough attention to that, that as, as the, the younger the person comes in with better tissue quality, that we can proceed faster? Do you think physicians are just stuck and that go slow?
Amee:I, I, I think, I think it depends on the physician and their population. And I think, you know, there's a, there's a, there's a need to fulfill the satisfaction of the patient and the patient's expectations. And certainly, um, I think that, you know, high quality physicians are really based off science. And they're trying to make the best judgment that they can for the patient. Um, I think, you know, sometimes we all get in a rut where you just get busy and you, you don't pay attention to some of the details when you're referring a patient to rehab. But I feel like we should have scripts that we should be going to the physicians that we work with and saying, I would love this little piece of paper filled out and has some of those characteristics on there so that this way you could be as diligent as you would deem appropriate from a standpoint of, uh, the first maybe three months of rehab. Um, and then how quickly you might start strengthening based off what the pathology was and even if you just, you know, kinda followed the surgeons. Protocol you had a better understanding of the patient that you're working with and the, and the factors that were addressed in surgery. So I, I don't know. I, I think, I think you get a mixed bag just like you do with any other profession, where you always have people, you know, Kind of working at the top of the game and they're making really science based and what the best decisions that they know for their patients. And then you have others that may, may not be, and they're just kind of falling back on what they learned when they were in residency and fellowship or whatever.
Mike:Yeah. And, and that's probably always the case. Um, you know, I was really fortunate. I mean, my mentor, Kevin Wil and, and Dr. Andrews, I mean, I got to witness them work together on that. And the communication it was, was top notch. Um, you know, Dr. Andrews would just walk right downstairs and say, Hey, I have this person coming. It was, it was only a medium sized tear, but the tissue quality was terrible. So let's go slow. Let's go on, Let's go on the, Protocol. And you know, Kevin really had some really good foresight with that and developing that like, heck, 30 years ago now, where there's, there's different types of, of rotator cuff tears. Um, and, you know, I, I think that makes your outcomes so much better when you can customize the progression based on the person and I. I think it's comical that we have to say that, right? It's like, yeah, duh. Like of course Like we should be customizing that. So maybe we're at the point where it's not that you had a rotator cuff repair, but we gotta get a little bit more specific about the details of that rotator cuff, right?
Amee:I think, I think you're dead, dead on there, Mike. I think you grew up in an environment similar to, to what I did from a standpoint of mentoring where I was working directly with the surgeons. I would spend two afternoons in their clinic and I got to see what. A bad outcome was from their surgeries, right from the surgery side, and then, you know, getting a standpoint of direct communication. I got to see. Exactly what I was dealing with. So I, you know, I think that environment is a great environment. Not everybody has that. So I think, you know, working with your referral base to try to improve the communication is the best that we, we can, I think, I think the surgeons appreciate those questions, to be honest. They just don't wanna be interrupted in the middle of the day by therapist, Paige, and I, and calling, I'll try to get the information. So if you facilitate that in, in, in a way that's conducive for. I think they're gonna appreciate the patients are gonna definitely appreciate it.
Mike:Yeah, and I think I would also probably recommend is becoming very friendly with their, uh, nurse practitioner, their physician assistant, or whoever's, uh, helping them in their office. To me, that is almost invaluable, and I've found that person to be very receptive to just quick emails or phone calls or even text messages. If you can get to that point. Just say, Hey, you know, like, how'd it go with this? And, and I think they respect why we're. Right. So they want to answer because they know it's in the benefit of the patient. So, you know, I'd recommend that to you, not, not everybody has a great relationship with the physicians in their community, but at least maybe try to make some relationships with some of their clinical staff. That could help too.
Amee:They're, uh, completely on board with that.
Mike:All right, so we talked a little bit about range motion, We talked a little bit about I mobilization, awareness link, stuff like that. What, what about strengthening? Cuz this is, this is one that sometimes physicians will say even wait 12 weeks, right? Which is, you know, no other repair. Would we do that with Right? So what are your thoughts on strengthening and how do you know when to start, how to progress? What do you think?
Amee:Yeah, no, I think, I think, again, you're gonna get answers all over the board depending on who you talk to. It, it, it that's dependent on the same factors that we've discussed. Age, hair size, whatever, but you know, the load that you put through there, as long as it's gradual and as long as it starts in a way that is aligns with what they're doing with a daily activity perspective, you're doing the best you can. So you can't tell someone they can brush their teeth and kind of use their arm for daily function, but then they can't do, you know, um, light resistance with the arm at the side that doesn't, doesn't really make sense like, So from that perspective, I think, you know, I would, I would te I would tend to think that massive repairs the older person I might hold off until three months. Um, but that's only out of habit. I think there are some things that we could do that are, um, completely safe. Um, but you know, you just have to understand what tendon you're working when and make sure that you're not overstressing it. So I don't have a. Great answer for that, except for the fact they use the same parameters. If it's somebody that had a, you know, if the tear configuration is longitudinal and it's a partial or a slow grade full thickness, or small full thickness tear, then gosh, you could probably start strengthening a lot earlier than what we've been, because you have so many other tendons around taking the forces, and you're probably not putting'em in a position where you're really gonna stress that.
Mike:Right,
Amee:I think, I think it is the spectrum. I don't mind a few patients at the three month mark. I know that that's probably not your population, Mike, but I think it just depends. If it was somebody that's 50 and they fell and they're mountain biking and they're uh, you know, weekend warrior and they really are active, but they had like a full centimeter. I'm probably not gonna wanna bend on that if the physician saying, Let's, let's wait until three months to strengthen. But if it's somebody that has a small degenerative tear and they ended up having surgery, then yeah, I would, I feel a little bit better about that. So there's no.
Mike:Yeah. I mean, because again, it's not, I mean, I don't think it, we're doing ourselves justice by just calling these old rotator cuff repairs. I mean, like what type, I mean, how big, What's the tissue? It's just too big of, of a conversation in my mind. So, um, to me, I, I think that's like the big, you know, the big take home from this here is that we get, get out of the, the context in our heads that all rotator cuff repairs are the same, Right? Um, not, not only are they. You know, change what their outcomes may be, both structurally as well as, as their, um, like functional outcome scales, but also just what we're gonna probably do with them in their progression. So the more you can communicate with the physician and what they do and learn about that, and hopefully over time gain some trust that you can collaborate and talk about that, then I think that's, that's the best thing for the outcomes of the person in front of you.
Amee:And I, I used to use the analogy, ah, it's not like an ACL or it's just an acl. Now I've learned so much more about acls that I can't even say that, right? Like, well, you know, then I'm like, Oh, maybe the bone bat teller. Bone, like igra. Okay. I could just use that as my example. It's still not the same thing as what the variability that you have in the factors for, uh, rotator cover pair. But, you know, I, I, I think the knees just around to carry the shoulder
Mike:I like that. That's pretty good spoken as a true shoulder therapist. I like that. Um, you know, and I, I get the, the physician's perspective too. I mean, some of the outcome studies are daunting. I get that. And you don't wanna have. Uh, structural failure that stinks, right? Um, you know, if you look mechanically at it, think about it. If you have a, if you have a large retracted tear with really poor tissue, they really have to mobilize that tear and repair it down that it almost seems like there's such a biomechanical disadvantage of that repair to actually stay intact. It, it almost seems unrealistic to think of anyway.
Amee:So very interesting. A paper recently came out from, uh, a group in Detroit, Michael Buy's group, and they had a small sample with. Lawrence says, lead author on this paper, I believe, where they embedded these. Titanium beads in the tendon so they could figure out where, where the tendon was after this repair and is there, what's the structure right? So just imaging it cuz you always get some artifacts. So they wanted to see what happened with these patients. What they ended up finding with ultrasound was that the majority of these tendons have a tendency to stretch. And so even if the repair is intact, Now we have a distended tendon relative to the native tendon. And is that why maybe in these degenerative tears, and these are, none of these were acute tears, um, why in these degenerative tears? You know, we just start to see some changes in the muscle that continue to happen as they get older. Um, and it just might not be that the tendon can be repaired in a way that it. Really high functioning. That was, you know, very small sample. 10, 10 subjects in that study. But it does make you think, Boy, what are we really doing?
Mike:Right. Exactly. Right. Well, I, I, I, I thought that was amazing. That was a fascinating study. Um, great conversation about rotator cuff repairs. I love it. Uh, before I let you go, I'd like to end with a little segment called the High five. I want to hear about. Kind of, I, I wanna dig in, hear about you and your growth mindset a little bit about that. So we can all learn from you an established veteran, you know, leader in our field, you know, still using their brain to grow, which I, which I love. So first thing is, what are you currently working on for your own ConEd right now?
Amee:Yeah, I'd love to say I had time that I'm dedicating to this, but if I had more to. I am very interested in the neurocognitive aspects. I feel that's, that's been of rehabilitation, like cognitive load. What are we doing with our return to sport, um, uh, rehabilitation. I feel like that's been something that is very novel to me. I think we've, there's more information coming out on this, on a, on an annual basis over the last five years, and I really think from a rehab perspective, we could probably do more reactive. Training and cognitive loading, um, and how we could maybe improve the scenario with regards to, uh, central changes that may, may occur. I, you know, it's just something I, I never thought about and as a clinician, we always kind of worked on strength, made sure cutting looked good, but we'd never really thought about like the, the, the neurocognitive part. So I think that that's, that's, that'd be, that's certainly an area of interest.
Mike:Yeah, I look forward to learning more about that too, as, as we grow. I, I feel like it's in its infancy a little bit. I think we all see the merit. I think we all see, you know, where this is going. But, um, it's gonna be impactful. I think it's gonna change a lot of what we, what we do in the future. For sure. Um, sweet. Uh, second question. What, uh, what have you currently changed your mind about clinically?
Amee:No, I think the diagnosis of instability, you know, um, not, and, and I'm not talking about like. Dislocated cuz that's a pretty easy diagnosis. But you know, this subtle winds stability or multidirectional instability. Um, the, you know, now I've, I I've evolved that It can't just be a pain reproduction. You know what, what I, I don't think if you put somebody in an apprehension position and that just reproduces pain, a te. And it is reduced when you do a relocation, that that is really instability. So I think, you know, my, the true definition of a a a A positive apprehension can't really be pain. It has to be really related to the sensation of instability. Now, is it something else? Sure. It could be, it, could it be that they're lax? Sure. But is it truly instability? No, I don't think the surgeons think that, and that's been an evolution and, and probably. My kind of shortcomings, um, previously just using pain.
Mike:That's a good one. I like that. Um, what's your favorite piece of advice that you give your, your students that you work with?
Amee:Oh gosh. I think the big thing is, is never lose the why you are doing what you do. And the whole reason we went into this was to help patients. So when you start to lose that as your focus, that's a problem. Okay, so I think, you know, the reason I wanna be better at what I do is because I, that person that's in front of me, I wanna help to the best of my ability. And I think that, that, that's certainly something that we always need to keep in our mind. Not that we need letters after our name. It's not that we need to do all these things cuz I wanna be, you know, certified in this, specialized in this. It's really cuz you wanna help the patient and that's why you.
Mike:I love it. That's a good one. Um, what's coming up next for you, Amy?
Amee:Oh gosh. I don't know. I'm just trying to keep. I'm trying to get the instability guidelines to a final draft, so that's gonna be a bit. Um, and I'm just working on some projects really. I have a, a project that I'm doing with, um, a bunch of sports therapists who are very interested in return to sport testing and so hopefully we have a manuscript coming out on that in the upper extremity, which is exciting. Collaborations, uh, that are extending beyond that, uh, that, that, that project. And I have a couple PhD students presenting at some conferences coming up, ORs and so forth. Uh, not so much with csm. I'm excited to see some sports content at csm. Looks really good.
Mike:I like it. I felt like that was a pitch. I like that. That's great. But, um, I, I'm looking forward to that, uh, return of sport paper. That'll be good. We'll have to get you on for another episode to, to discuss that. That sounds great.
Amee:Yeah, there's some really great minds behind that that I'll, I'll, I'll pitch their names cuz they're really, really up and coming, uh, sports PTs. So I'm excited.
Mike:That's great. Awesome. All right, well, how do we learn more about you and your research and all the things? How can we find out
Amee:Yeah, just the internet. The internet is it right?
Mike:Pub
Amee:I don't have a, Yeah, my, my own page. There's probably a link to my, to my research lab, um, at Northwestern. But I think, you know, most of the things that I do are associated with, you know, some of the things that we have going on here, the physician collaborations, and I'm always interested in collaborating with other groups. Um, but, you know, yeah, I guess you have to kind of find me. I'll try to find you
Mike:Yeah, exactly. I like that better. That's perfect. So, but yeah, grab, grab Amy if you see her at a, uh, a meeting. Obviously she's, uh, she's great to chat with and, and talk about more of her research. I think she's being humble. She got more research out there than she's, than she's letting us know. So, uh, she got a lot in that mind. So, uh, Amy, thanks so much. This was amazing. I really appreciate you taking the time and, uh, uh, sharing all this with, with the audience. Thanks so much.
Amee:Well, thanks a lot, Mike. I really appreciate the opportunity to talk with you, and it's fun as always.
