The Get Healthy Tampa Bay Podcast

E144: Dr. Robert “Bo” Lewis on Shoulder Pain, Rotator Cuff, Labral Tears & Frozen Shoulder.

• Kerry Reller

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Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week, I’m joined by Dr. Robert “Bo” Lewis, an orthopedic surgeon specializing in shoulder care and sports medicine. In this episode, we break down why shoulder pain is so common, from impingement and rotator cuff tendinosis to labral tears, instability, and frozen shoulder. Dr. Lewis explains age-specific patterns (youth athletes vs. 40s–50s vs. older adults), what symptoms point to each problem, and how he thinks through treatment—physical therapy, targeted injections, arthroscopy, and when anatomic vs. reverse shoulder replacement makes sense. Tune in for practical tips to protect young throwers, manage night pain, and know when it’s time to see a shoulder specialist.

Dr. Robert G. “Bo” Lewis is the founder of Coastal Shoulder Surgery & Sports Medicine and has specialized in shoulder surgery since 2006. A board-certified, fellowship-trained orthopedic surgeon, Dr. Lewis focuses on arthroscopic shoulder procedures and sports medicine. Before medicine, he earned a business degree in risk management from the University of Georgia and worked in Tampa before completing his medical degree at the University of South Florida. He went on to complete his orthopedic residency at the Medical College of Georgia and a fellowship in shoulder surgery at McCluskey Orthopaedic Surgery.

Dr. Lewis has performed more than 10,000 arthroscopic procedures, with expertise in rotator cuff and labral repairs, biceps tenodesis, and superior capsular reconstructions. He and his team pioneered a technique for performing shoulder surgery without general anesthesia. His practice also treats sports-related injuries of the elbow, hip, and knee, including ACL reconstructions and Tommy John procedures. Dr. Lewis is a Fellow of the American Academy of Orthopaedic Surgeons and an active member of the Arthroscopy Association of North America, Southern Orthopaedic Association, Florida Orthopaedic Society, and Florida Medical Association.

00:28 — Origin of “Bo”
01:33 — From business to medicine; carpentry → orthopedics
05:24 — Why his practice is 90% shoulders
06:42 — Why shoulder pain is so common (golf ball on a tee)
09:50 — Young athletes: growth plates, laxity, labral/labrum issues
14:22 — Pitch counts & protecting developing shoulders
15:58 — 40s–50s: rotator cuff tendinosis, bursitis, night pain
18:51 — Impingement explained and daily triggers
22:31 — Frozen shoulder: risks, phases, treatment approach
34:29 — Older adults: cuff tears, pseudo-paralysis, replacements

Connect with Dr. Bo Lewis
Website: https://www.coastalshoulder.com

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Kerry:

All right. Hi everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have Dr. Bo in quotes, right, Lewis, but your real first name is Robert, right?

Robert:

that's right. That's correct.

Kerry:

well, why do you go by Bo?

Robert:

Well, that's a long story. Years ago, I guess when I was, well, the way my parents told it anyway is when I was two and my sister was three she would always try to call me a bad boy and she pronounced it bo at the time. So it just came out bad Bo. Bad bo. And so at that stuck and then, you know, when I was supposed to get real mature and grow up and go to high school, my mother said, well, maybe you'll wanna be Robert now. And so I got to high school and that lasted all of about the first half of the first day. And so I went back to Bo and, and then college I thought, yeah, now I'm definitely gonna be a Robert. But I stayed Bo for forever and still am I guess.

Kerry:

That was a pretty good story. It's definitely a fun name, I think, or nickname. Yeah. So tell us, other than your nickname, tell us a little bit about who you are and what you do.

Robert:

So originally I'm from Savannah, Georgia, and I grew up there and, and went to college at the University of Georgia where I got a degree in business and risk management and insurance, as the major was kind of described, but mostly risk management. And while up there, just, you know, I love the water growing up in Savannah, but I kind of wanted a larger city down in Florida mostly. And Jacksonville and Miami, they you know, I looked at them, but then I just really looked into, looked at Tampa, the Tampa Bay area, and really fell in love with it. So, right outta college, I moved down here and I looked through the yellow pages for, places to work and called on a few places in the Principal Financial group. Over on Rocky Point was who I interviewed with and a, a really good mentor of mine. Dale Sells was my boss and he still lives in West Chase over in Tampa area, but just a great guy and did 401k planning and, and retirement planning, employee benefits for a couple of years with those folks and just really miss the sciences. And yeah, I just, and I always liked the sciences and math and things like that, so I wanted to go back into healthcare and I thought physical therapy might be a good avenue for me, but, but then as I kind of went through it and all, I, I thought, no, I think I'd rather go to medical school and my advisor at the time at USF where I was doing some post bachelorette work to get my science core and so forth, she. She said, well, you know, your undergrad scores are not stellar. They're not the perfect scores to get you into medical school and or to therapy school at the time. Excuse me. And she said, you need a backup plan. So I came to her a week later and I said, I've got my backup plan. I'm gonna medical school. So she just kind of put her hand in her face head and face in her head and just said, you know, what are you, who is this guy was crazy. So anyway, got got good grades from then on out and, wanted to go to medical school and got in here at USF in Tampa. And after that I found that I really wanted to do orthopedics. My father's a carpenter, so I grew up with him and worked with him since the time I was probably eight or nine, and worked my summers with him, building houses, remodeling houses, you name it. And so it just made sense, you know, orthopedics, I could do some carpentry, but maybe in a, in a nicer setting. And things like that typically. So I went to, I went to Augusta for my residency in orthopedics and in residency I really started to fall in love with the shoulder. It seemed to be the most difficult joint for a lot of the resident talk about and describe and fix and whatnot. And so I really, really enjoyed that. And looked for a fellowship and I found one in Columbus, Georgia with George McCluskey and spent a year there. And then, stayed on with the hospital after I, I, I was in Panama City working for a little bit and then I moved back to the hospital. They wanted me to come up with a sports medicine program up there at the hospital and also co-direct the shoulder center, which I did for, for many years, and then went into solo practice. Back in 15 and been in solo practice ever since, and moved down here to the Tampa area just to get back recently a couple years ago. So new, relatively new practice to the area. But, I've been coming down here for, you know, gosh, that's, I don't want to necessarily date myself, but, but, but a long time ago. Moved down here, back, actually back in the nineties. So been around the community for a long time.

Kerry:

I mean, your background is so unique. You could have gone so many different ways, like the business side, which we don't see many, you know, medical professionals knowing much about, and then obviously medicine and even the carpentry thing. It's, it's pretty exciting. We're happy to have you here. Course and you are your practice like totally. Well no. You said you do sports medicine also, but mostly everything is focusing on the shoulder, hence the name of your practice, obviously. Right.

Robert:

Correct. We probably do about 90% shoulders here. And the other 10% is you know, mostly knees. But arthroscopy is where my training really is. And I'll, I'll scope shoulders. I do elbow, arthroscopies, wrist scopes. I even do done some recent hip scopes. And do some knees for meniscal tears and things like that. Even have some patients who need ankle scopes, but pri predominantly it's a shoulder practice. But you know, even if people come in and they have tennis elbow or trigger fingers, carpal tunnel. I don't send'em away. You know, I did a trigger thumb earlier this week and did a knee scope last week. Did some shoulders. So, so we, we do a, I wouldn't say it's a general orthopedic practice, but I do a lot of the same stuff. It's kind of hard to tell a patient when they have a carpal tunnel to go find somebody else when you know you can do it. And I've done a, I've done a lot of them, so we keep a lot of stuff in-house.

Kerry:

Awesome. Yeah, so we were just talking before about how this shoulder is like a difficult joint, not just to, you know, treat and, but also to diagnose. And that primary care sometimes has a difficult diagnosing it that, so I was wondering why, why do you think shoulder pain is so common? Why do you think almost everybody experiences that some point in their life?

Robert:

Yeah, well, good question. And thinking about that, I think it's, it, it, it relates back to two things. I think number one. I think the, the shoulder joint has the, has more motion than any other joint in the body. It's ball and socket joint, kinda like your hips, but the hip joint is, needs to be a little more stable'cause it is weight bearing and our shoulders aren't necessarily weight bearing. So it's kind of cradled the ball is more cradled by the cup, whereas in the shoulder it's more like a golf ball and a golf tee, and the tee has some ligaments that surround it to kind of keep that golf ball on there. So most of the motion, means that well it's probably gonna bump into a lot of different things at various ranges of motion. The other reason I think, is that our hands are connected ultimately to the shoulder, and that's what we use every single day. That's what the human beings. That's how we separated ourselves from other species is our hands. And we have to position our hands in space. Everything we do is with our hands all the time. So when we position our hands in the front of ourselves, like this, for example, we're bringing that shoulder up underneath. Part of the shoulder blade. That is a very common position that people experience wear and tear on that rotator cuff that people have heard about. That creates a lot of pinching and so forth. So actively using our shoulders, whether it's in sports as young, young children and every day, look at our housing and, and everything where we store things in cabinets up ahead, overhead. And so we have a lot of overhead activities, whether we like it or not. Hanging up a, a robe, maybe after a shower or a towel or reaching up for the cereal or something. Or that coffee mug in the morning, putting things away in the closet for the medical assistant. You know pitchers, volleyball players, you name it. So a lot of overhead activities can create this. The fact that we use our hands more than any other. Part of our body during a daily basis, and the shoulders are gonna help position that handed space. A lot of those things combined will create that pain. The other reason is, is that the rotator cuff, the group of muscles that kind of rotates the arm and moves it in space, they live in a very tight area and it's, it's quite efficient, but yet if anything goes wrong or gets inflamed and angry, it's kinda like swapping out your size eight sneaker for a size seven, and then trying to run down the street things get tighter and they start to pinch and tear, create bursitis or tendonitis and things like that. So the proximity of the bones in the shoulder can also lead to advanced wear and tear and inflammatory scenarios that can occur on a daily basis.

Kerry:

Yeah, so the shoulder, like you said, definitely a complicated joint that, I guess, versatility of it, and it's just makes it more vulnerable. Right. To all these things that we do repetitively every day. So you mentioned obviously some athletes already, and what would you say is the most common injury in the shoulder in the young athletes?

Robert:

So, in the younger athlete, first of all, athletes are either skeletally, mature or they're skeletally immature. And all that means is that an athlete, a young athlete, may still have growth plates open and if they have growth plates open, typically we've learned that the growth plate is the weakest link in the system. So a young athlete who might be a baseball player and, and throws a lot, they're gonna start to get what we call little leaguer's elbow. They can get little leaguer's shoulder and the growth plate will try to shear kinda like if you're trying to take two layers of a cake and you're trying to turn'em, that icing in between the layers can shear sometimes, and that can create what we call inflammation of that growth plate, or apophysitis as we call it. So a skeletally, immature young patient is gonna experience apophysis and things like that. The skeletally mature athlete, so teenagers, later teenagers, and even in their twenties, it, the bones hold together just fine. The growth plates are done, and now they start to experience problems in the shoulder where they meet the extremes of motion. So we, we think of. Good athletes as being loose. They have laxity we call looseness, laxity, and laxity is a good thing. Hardly do we ever bump into. The athlete has a very tight group of joints, that just doesn't work. So they need that laxity. Now it's good to be loose and lax, but when laxity becomes painful, we don't call it that anymore. We call it instability and instability is what happens when the golf ball, as we talked earlier, the golf ball and the golf tee relationship is disturbed. And if we can keep the golf ball on the golf tee, the rotator cuff muscles work very well. It's like having a hinge and it, and it's like shutting your door. We have all the hinges on the door shuts very easily. You take a few of those hinges off the door is very awkward to close. So once they develop this instability, that ball starts to slide back and forth and, and the rotator cuff can become fatigued and then they start to hurt. And, and so now we've got looseness that hurts or instability and they can stretch their capsule out in the joint the shoulder. They can have labral tears. We probably, some athletes have heard of what's called a slap tear, and that indicates a lab tear that's on the top half. If you think of the golf tee as a clock, anything that's above the from three, from nine o'clock to three o'clock, in that top half of the clock, we call a superior label tear within the front. Call it anterior in the back of P, so SLAP. If you have a lab tear on the top half of that clock, we call it a slap tear. Anything down below, we just call it a labral tear. So that's what the skeletally mature young athlete can get. Labral tears, instabilities. And if they're in contact sports, they can get dislocations. And those are acute, violent labral tears, such as a football player who's trying to reach out for that. Running back, flying by him, and he tackles him and his shoulder dislocates out the front. His labrum now just got ripped off. We call it a bank card tear sometimes. Offensive linemen may block so much that their, the, the humeral head or the ball on the golf tee is pushed out the back and they start to develop posterior instability or instability in the back. They can even develop labral tears in the back. Micro traumatic injuries. Throwers and volleyball players, overhead athletes, and even swimmers, they can develop a lot of stretching of the capsule in the back, which leads to posterior instability and we see it. And I see a lot of that in my practice. A lot of overhead, skeleton, mature younger athletes.

Kerry:

I think one of the thing that bothers me about the shoulder is that they have names for like, everything. You just, like, probably someone's, you know, discovered it or labeled it and then they named it that. Right. I know the slap one is a little more mnemonic, but even for the, the test. Right. Like when we're, I mean this might be not helpful for listeners, but people who are at least went through some more sort of medical rotation with like the Hoffman's and the near test. Like everything has somebody's name on it and that's what something that I found quite challenging.

Robert:

yes, yes.

Kerry:

all this, but well you mentioned obviously the the young athletes with the growth plate still open. So regarding sports, like they have certain number of pitching they're amount to do per week or month or anything. Can you just comment on that, like why they have those kind of rules for young athletes? I mean, I know they have'em for a little bit older, but young athletes in general.

Robert:

Sure. So what, what we found and what, what our literature has kind of found is that at, at a certain point, a certain number of. Pitches and so forth. We, we the throwers start to reach a certain level of fatigue. Joint stability is a combination of your, what we call the static components, what we call the dynamic components, static, as you might imagine. Those are the things that aren't, you know, you can't really change's kind. How you're, you know, how were you were born. What's the shape of the ball? What's the shape of the golf tee? The labrum, the ligaments, dynamic components are things like muscles, things that you can get stronger, and when the two are combined static and dynamic, you have a real stable joint. But when you throw and you throw and you throw, your dynamic components start to fatigue. And now all of the stress is on the static components, which could mean you're hurting the growth plate, you're hurting the labrum. You're hurting all other structures. And so that is very important for us to protect those children when they're young.'cause a lot of'em will, they'll just keep throwing, they'll just keep going. But we have to protect them from themselves and from their parents and from their coaches to not throw as much. And we find that those numbers have really, have really done a real good job of, of, of decreasing injuries, especially at the growth plates over the years in the elbow and the shoulder.

Kerry:

Yeah. That definitely makes sense the way you describe it that way. So we talked a little bit about the young athletes. So what about middle aged adults? What's kind of tends to show up in people in their forties and fifties shoulder injuries?

Robert:

Sure. So once we once we mature to that level, we like to use the word mature here at Coastal Shoulder. We don't like to use age or anything, but as we mature the 40 and the 50 year olds they get more of a, a rotator cuff type issue. Your rotator cuff, the tendons that attach to the ball we've talked about, they're typically about a, about a quarter of an inch thick. And that's kind of like tread on your tires now you can leave the new car lot with brand new tires and your tires are great and 10,000 miles. If you drive well and you have good alignment on your car, your tires are probably doing fine. Maybe they'll ask you 60,000 miles. And the same is true about the rotator cuff. It it, it does wear down with time. Now we're not like tires and we do heal. So there, that's why we last longer than cars and we don't have to have as many tire replacements and things. But as we mature we know from certain studies like MRI studies that show that our blood supply of the tendon will decrease a little bit. We also know that we start to develop this condition known as tendonosis, which is degeneration of a tendon. And when we look at this histologically, so we look at the tendon under a microscope, we see that it's got this, what we call muo degeneration and collagen the protein that's in tendons lines up very nicely and it's a really, really well organized rope, one of those brand new ropes that you wouldn't mind repelling off a cliff with. But tendinosis is one of those frayed ropes and things are a little disorganized. And you might say, well, I don't think I'll repel down the mountain with this one, but maybe my buddy can. And that's what, that's when we start to experience discomfort and pain. And what happens essentially is we can't heal that section of the tendon quickly enough in a day that if we have a certain amount of damage a day, we can't actually repair that enough. So the next day, it's almost like having an inbox in an outbox. If I got too much of my inbox, it's gonna be there tomorrow. And that's what happens. It accumulates and then it develops tendonitis, or not really tendonitis. There's not really a lot of inflammation in the tendon, but it, it, it kind of. It helps patients understand what we're talking about. But then they get bursitis inflammation of a structure above the rotator cuff tendon that causes that night pain. It can't get comfortable. It, it aches right here in the middle part of the arm. It's not the shoulder. It's not the elbow, but right in between. It's that dull toothache that wakes me up at night. I can't sleep on it correctly. My, my, my husband's already kicked me out of the bed, put me in the recliner chair or vice versa, and, and then that's when they. Start to come in because they have all this night pain and that's rotator cuff stuff that we see mostly, predominantly in that 40 and 50 year group rotator cuff.

Kerry:

And what about impingement syndrome? What is that?

Robert:

Sure. So as mentioned early on, and why does why does the shoulder get a lot of pain and the anatomy has something to do with that? So in the shoulder we have we have the ball, the arm bone has ball at the top, and then right under, right on top of that, kind of like a carport. We have an appendage of shoulder blade or the scapula called the acromion. And between the acromion and the humeral head lives the rotator cuff. Now as we lift our arms and as we come up and then in this position rotated in and in front of us, we are at the maximal location of impingement. And actually those two bones start to pinch and impingement by definition is just a pinch, and they'll pinch the tendon and that tendon will hurt a little bit, and then they'll, you'll pinch it again and again. We live our lives in front of our body up overhead, and so we are experiencing and impingement. A hundred thousand times a day. Now, as I also mentioned, this system was built very efficiently. It's very cool. And so there's not much margin for error though. And once you start to get a little tendinosis and your tendon goes from, let's say quarter an inch thick, and now it's oh, a little bit more than that. Now it's thicker. And again, that analogy, it's kinda like taking, taking your foot out of that size eight sneaker and putting it in a seven, and then trying to run, it's a squeeze on the tendon and that can actually accelerate and then basically push that tendon into a further state of what we call tendinosis or degeneration.

Kerry:

So that ends up having what, limited range of motion or how does that present?

Robert:

Sure. So usually impingement if if your arm, if it hurts to reach up and usually the complaints are, it hurts when I reach up in the cabinet. So I, I don't like to do that. So they'll start to not do things that will increase their range of motion. They'll also say, well, it hurts to reach back behind me like in the backseat of the car, for example. Things like that. And it'll give'em that toothache pain in the mid part of the arm. They won't like to throw baseball. Batting practice with the kids. They won't wanna shoot basketballs with the kids late at night. They wanna, they haven't played golf in a while. So those are kind of some of the things, it can decrease range of motion only because they're not using it that much. But, but it, it doesn't necessarily mean that it going to stay stiff or progress into a stiff shoulder, which is another thing we'll probably talk about our frozen shoulder at some point. But rarely does an impingement syndrome move into a frozen shoulder, but it, it's, it's not unheard of, but it would be rare to do that. But range of motion restrictions. Active things that you do, you don't typically want to do with impingement syndrome and sometimes it's I've seen it both ways. We have, we measure these things called acromial indices. We look at the acromial index or the shoulder angle as we also call it, and that can dictate whether or not your acromion is actually you were born and you have a disadvantage some people space between that acromion, it's, it's sloped. It actually can create a rotator cuff tear for people in their thirties and they don't even know. And then they get to come to see us typically in their mid forties or fifties. And the rotator cuffs have been torn for years, and it's hard to repair, if at all. Some people have wide open spaces and they never have a shoulder problem. So it can be your anatomy and just your parents that help create your shoulder the way it is that can make your impingement syndrome better or worse, or maybe you never even experience it.

Kerry:

Well, you mentioned frozen shoulder. So tell me about that, and who's at risk for that?

Robert:

So frozen shoulders is, is typically a global loss of motion. The medical term for it is adhesive capsulitis, so as that might imply the capsule which is the structure of that if you could take if you could take the shoulder, the golf tee and the golf ball, and you can kind of put them into a, a bag of water and they're just partially inserted through the, the lining of the water, and now they're in there touching the water, that's, that bag would be your capsule. Holding the joint fluid inside. So that capsule typically is very loose and it's you know, just like your, your sleeves under your, your quarters up there. When you lift up, it allows your arm to lift up because there's a lot of looseness underneath the armpit. Well, what happens in adhesive capsulitis, there's inflammation at the level of the capsule and it actually starts to contract and get tighter and thicker. And so then if it's thick in the front, it's hard to rotate the arm out. If it's thick in the back, it's hard to rotate in. And if it's thick in the bottom, you can't lift it. And the arm kind of goes up like this. And, and then women usually come in and the first thing I ask them is, you know, so you, you know, they can't get their hand back behind their back. So typically I've learned to ask because they always say, you know, I have to strap my bra in the, in the front and spin it around or'cause they can't reach back behind them. So they've lost internal rotation, external rotation, elevation, everything. So it's a global loss of motion and it really hurts. It's a very painful situation. And frozen shoulders have three fa phases. People typically are freezing. And they're going up the slope. Then they become frozen, which is a plateau, and then they start to thaw, which is basically coming down the slope. Now that whole timeline, if nobody seeks any kind of conditions or, or, or help or advice, usually can last about 18 months. So if they come to see us, either primary care or specialist, whatever, we hopefully are intercepting them at a point. We're meeting them on the freezing stage. That's when they're very painful and we put'em into therapy and we maybe give'em some anti-inflammatories and we get'em to plateau or start to, we, we get'em frozen, we want'em to freeze be done, and then they can fall out and we can abbreviate that 18 months, hopefully to about six to nine months. But in any event, it's gonna be a long haul with a frozen shoulder. Now who's at risk for th at the number one group that we see frozen shoulders in are postmenopausal females. We think it's an estrogen imbalance and that can be related to the why they get the capsule and, and why they get the capsule tightening and thickening. And it can be. Anything that really can start the frozen shoulder. Maybe they bumped into the door jam going to the bathroom at night and the light was out. Maybe they had to you know, pull the garbage out of the can a little bit more than last time maybe they had to help out with a, a show and they were. Carrying a lot of tables around, whatever. It's something simple and then it just sets it off and, and most of the frozen shoulders we see are idiopathic or they don't really have an identifiable injury. It's just something happened that then created that cascade of inflammatory factors that come in and really create that stiffness. Other folks who can get frozen shoulders, we see it often in diabetics, but not as, not as often as postmenopausal females. They're number one. But diabetics can get it. We have seen it in some folks who I think alcoholics are on the list and even folks with thyroid disease, but rarely do I see that population kind of coming in with that frozen shoulder. It's that, that postmenopausal female that I'll see, 99 out of a hundred frozen shoulders will be in, typically in that population with the number two most frequent probably diabetes.

Kerry:

Yeah, I mean, I think, I mean I've been very into learning about the menopause transition lately. So I feel like we keep hearing all these weird orthopedic things that you know, occur with that. And it's definitely, you know, common and we see in our practice as well. And then send them to people like you. And sometimes I know physical therapy definitely helps a lot. Right. And sometimes there's a role for injections as well. Mm-hmm.

Robert:

Yes. Actually years ago when I was in residency, we had an article come through the journals. And the article was talking about treating frozen shoulders and the recommended treatment was benign neglect. And what they found after looking a lot of patients that if you just ignore it, it'll go away. Eventually. Benign neglect. It does. Now we always have to fix something. That's what the ortho pods want to do. You know, we gotta fix something, you know, gimme something to do. I can't just babysit. You know, I want to get out there and do something. So, so then we, we started thinking, well, maybe, maybe things have changed. Maybe if we can operate on these folks, change, you know, do a, go in there, do a manipulation, do what's called a synovectomy, remove that thickened capsule and all the inflammation. And so the study was essentially repeated 15, 20 years later. And guess what? It found out? Benign neglect. Best way to treat'em, leave'em alone. And not many of them need surgery, but we are in 2025. So occasionally somebody may come in and they say, listen, I've had this for nine months. I've been in therapy for four months. I've had two injections. I gotta get back to work, or My boss is gonna fire me. And so at that point, if they've really failed an extensive therapy course. Plus or minus good anti-inflammatories, we will offer them a manipulation under anesthesia, which will break through and tear through that thick capsule. And then we go inside and just kind of clean things up'cause it does make a mess. And they, and they have their motion back in three minutes instead of three months. As far as injections and who to inject, I usually offer injections to those that are coming in, in that freezing phase. That's the most painful phase. And if they come in and they're just sitting there going, oh my gosh, I gotta have something, you gotta do something. Or if they put me up against the wall and they say, I gotta have something, then I recommend a steroid injection, and what I'll do is I'll put half of the medicine on top of the rotator cuff because even though it's not the, the primary pain generator. That diskinetic, or the abnormal motion in a frozen shoulder causes some pretty advanced impingement. So I'm gonna put a little bit there and then I redirect the needle to put the most of the medicine or the other half, I guess in the joint so that it can treat the inflammation and the synovitis. Synovitis is inflammation of the lining of the capsule. The capsule has a lining, we call it synovium, an inflammation of synovium. It's called synovitis. So we wanna put that in there to help treat that. And actually that has done very well. I find that when I first meet folks, it's typically in that freezing phase. We send'em for therapy for at least minimum of two months. We do an injection and most probably eight outta 10 come back two months and they say, man, I feel so much better. I'm not a hundred percent yet, but my emotions so much better and I feel better. Thank you. And then that they just work it out from there. That benign neglect. Then they just continue to get that motion and once that shoulder isn't painful anymore. You don't mind reaching a little higher into that top cabinet to get the coffee cup. You'll, you'll push it a little bit more and it's, you're bumping into the extremes of motion at that point, improving your range of motion. And that's, that's what we want to get'em to so that they're an independent motion getter and they get it themselves.

Kerry:

I mean that, that makes a lot of sense. I like the, the ben benign neglect term too. That's

Robert:

Yeah. Yeah, that's, that's what, and they, I think they actually published it that way. The nine o'clock. A great way to treat it.

Kerry:

so we talked about like more mature adults. What about the really mature adults? What are they most at risk for? What do you see most in that population?

Robert:

Sure, sure. So partial tears and tendon the tendinosis that I mentioned earlier, we, we often refer to them as partial thickness tears and partial thickness tears. Someone might think, okay, well if anatomically you don't have a partial thickness, nothing's really torn, then you don't have a partial tear. But actually functionally, you can have a functional partial tear, two tendinosis if it occupies a section of the tendon and it doesn't allow the full strength or allows your muscles to have full strength, then it's by definition a functional partial tear. And those can progress. And sometimes they can progress to the point that they are, they become full thickness tears full thickness tears you might think, well, gosh, if I have a full thickness tear, I've gotta have a lot of pain. I have to have, no, I can't lift my arm there. How can I lift my arm with my tendons ruptured? How's that even possible? Couldn't be possible. Actually it is it's very possible. In fact, in the 60 I, I, I guess in the 60 year olds in the United States, we probably have about 20, 20 million in that, in that category 10% of them. 10 to 15, maybe 10 to 20% we think have full thickness tears. Okay. So if we do the math on that, we're looking at two to 4 million people, but we'd only do maybe 250,000 to 500,000 rotator cuff repairs a year. So why aren't we fixing 2 million or 4 million a year? And the reason is, is because literature shows us that a full thickness tear can generate normal strength at times sometimes it can give you great active motion. And if you're somebody who, let's say you don't like to exercise much and you just like to do simple things, you don't lift a lot overhead, but you have, you can maintain your overhead function. You sleep well at night. Your strength is good for whatever you like to do. And if you don't hurt, you don't come in to get looked at you. You just, you don't come to the doc. And, and that's what a lot of people do. So we can have full thickness tears in that population and even an older population. That will then be okay for years and years. However, if the tear starts to get bigger and bigger and then all of a sudden become what we call a massive rotator cuff tear, then sometimes people can lose the ability to lift their arm and it's as though they're paralyzed and we call that pseudo paralysis. They're not really paralyzed, but they can't lift their arm. So we call it pseudo paralysis. Now, once a person has gotten that far, if it's not from a rotator cuff strain, but they haven't lifted their arms in several years or months, it's very difficult to repair their rotator cuff and give them back active function because that rotator cuff has probably retracted, you know, so far away from the bone that you just can't get it back over, and it's scarred in. So we have different procedures for that population where we can arthroscopically repair the capsule or put a graft in there. And sometimes we have to do what's called reverse shoulder replacement to help them get back their function. So atrophy big, massive rotator cuff tears. And when I say atrophy, when that rotator cuff tendon is torn, the muscles that attach to that tendon were not a, they, they're not being asked to move. So they just sit there and they start to atrophy away. Just like if you had somebody has a spinal cord injury, their legs, if it's just below, you know, just, just the legs. Their legs will start to atrophy and shrink up in size because they're in a state of disuse and that's what happens in the shoulder. And we even have a classification that helps us to decide whether a procedure will be worthwhile on patients. And that's based on the fatty atrophy that sets up in the muscle. Of each of the rotator cuff rotator the rotator cuff is a tendon group, but it has muscles that attaches to it. So we look, we pay a attention to that atrophy. So when that more mature that really that 60, late sixties or even seventies and eighties, we may have big, massive rotator cuff tears that are not reputable, but sometimes, you know, you can actually get them feeling better if they're symptomatic. You can get'em feeling better with therapy plus or minus an injection, and if they can get some reasonable function back and pain-free status, they're very happy.

Kerry:

How often does it go toward shoulder replacement?

Robert:

Well, so shoulder replacements, we have two types. One we call an anatomic shoulder replacement. And what that means is that on the ball we'll replace the ball with a metal ball and we'll replace the golf tee with a plastic golf tee. The, the prerequisite for an anatomic shoulder replacement, of course, is a good rotator cuff, has to be there because that's the motor, it's gonna drive it. And like I had mentioned earlier in the talk, the dynamic and the static stability, they work together. So if you can imagine putting a shoulder replacement, an anatomic in a shoulder that has no rotator cuff, it's gonna have so much shearing forces and just like that athlete, that's fatigued, that's gonna slop around and it's gonna make it loose and it's gonna fail and we're gonna be back in the OR in six months to a year trying to replace this thing. But if they have an intact rotator cuff and they truly have arthritis in this shoulder. That causes their pain. An anatomic shoulder replacement is a great procedure for folks. Now, what happens to the folks that don't have a rotator cuff, but they have arthritis? Well, that's where the reverse shoulder comes into play, and we actually put it in backwards, meaning that the ball component goes on the golf tee side of things and the golf tee component goes on the humeral head side of things. And when you think about it, instead of you, you have, you create a fulcrum. So if this is my new top of my humeral head, it looks like a golf tee, but I have a ball now on the golf, on the, on the shoulder blade side of things. My deltoid now has a fulcrum. It won't slide up. It's locked, and now it can actually fulcrum up. And the deltoid at the end of the day is the main driver of the shoulder. It's the big power horse. It, it's the motor. It works, it works it. But we have to keep the golf ball on the golf tee in order to let the deltoid work appropriately. The rotator cuff keeps the golf ball on the golf tee. When that's gone, sometimes it can't stay there, and that's why we need to put things in reverse so we can maintain that fulcrum so the deltoid can work.

Kerry:

Very interesting. I don't think I knew that at all about the reverse shoulder. Okay, cool. So sp well you've done that and then you've done like more than 10,000 arthroscopic procedures. What advantage does that approach have over well how does that help ba patients like better procedure?

Robert:

So Arthroscopically you know, at the end of the day, it's just a, a minimally invasive approach. We go through small skin incisions, and when we go through the deltoid it just, the fibers kind of separate, kinda like driving a. Maybe a, a airboat through the marsh grass. It kind of separates and then comes back together again. That allows us access into the joint without taking down the deltoid or anything like that. Once we're inside, we can do work through what we call cannulas. They're like little tubes, and we have instrumentation that is very long and it's very, very well done. And we can, you know, place the tendon back on the bone. We can put screws and anchors into the bones where we have sutures that we can tie, we can tie through the cannulas now, and we have long extensions called knot pushers. So we can, it's kinda like building a ship inside the glass bottle. We can do that now with the instrumentation, but we don't have to take the deltoid out. Charles near. Who wrote the book on shoulder surgery years ago? Literally he always talked about. You know, part of a good rotator cuff repair is you got, you have to preserve the deltoid. You have to, you have to respect it. When we used to open, we would have to take the deltoid off, but then you better make sure you get that deltoid back repaired, and it's gotta heal. Because again, it drives the shoulder and if we do a bad deltoid repair, they have a deltoid failure. It doesn't matter how well you fix the rotator cuff, you're gonna be in trouble. So this arthroscopic procedure and technology allows us to bypass the deltoid and respect one of what Dr. Neer said. You better not disrespect.

Kerry:

Near, comes up again. Okay. So he is the guy that wrote the book. No wonder he has all this tests.

Robert:

There's a lot of guys that wrote the books for

Kerry:

I know.

Robert:

But he is he's a very classic guy.

Kerry:

Okay, so we've, we've kind of covered a lot of ground. Is there anything else that you'd like to add about, you know, specifically how you approach the shoulder or anything else that you wanna discuss?

Robert:

Well, you know I think for. I think for patients I think you just, you just recognize that if you're, if you're having shoulder symptoms or discomfort in the shoulder, and it's usually gonna be between the elbow, midway between the elbow and the shoulder if you have that kind of pain, it's dull, wakes you up at night, things like that. You probably could go to Vegas and bet your money that it's gonna be a rotator cuff issue of some sort. And most of partial rot, if it's a partial tear, seven out of 10 can get better with appropriate physical therapy, plus or minus an injection and a little time. And it, and, and, and the literature is very, very thorough on showing that there are great outcomes from that, from that aspect, if you're one of the three out of 10 that doesn't get better, well. We start talking about MRI scans to see what is the extent of your partial tear. And we learned back in the late nineties that when a partial thickness rotator cuff tear exceeds 50% of the original thickness of a tendon, it becomes surgical. In fact, we looked at a lot of studies before then, and it shows that if we used to, you know, we used to just go in there and maybe maybe shave part of that torn section. And what we found is that tendons that were less than 50% torn and we just debrided them, they did great. But if there was a tendon that had a 75% tear and we didn't fix it, they got revised 95% of the time. So that shaped the standard of care back at the turn of the century when we went from 1999 to 2000 and we've been measuring partial thickness tears and we find, and there were all kind of candle studies that came out after that. And that show that that's what, that they become surgical. So in the three out of 10 that don't get better, they probably got a partial tear that's surgical at that time. Even people with full thickness tears can improve. So I would tell PE folks, you know, if you have those kind of. Symptoms. That's probably what it is. Maybe in the more active person who says, well, I, it, my shoulder pain doesn't wake me up at night. It's only activity related. It's only when I throw, well, you don't have to be a teenager or a 20-year-old. Maybe you're still a very active 30 something year old or early forties, and you really, you just have a labral tear. Maybe you just have a biceps issue and if your biceps is painful, that can create a lot of activity related pain. Like, maybe I can't do my dips anymore at the gym. Or it really hurts when I'm, I can't, I can't throw batting practice my, my son ever again. Forget about it. And that's probably a biceps issue. So it, so it can be, you know, more than just one thing, but, you know, night pain, stuff like that. Rotator cuff stuff, activity related pain, maybe labral. Or bicep stuff, all of which we treat and things like that. If you have restricted motion and you have a lot of crunching in the shoulder, you could have arthritis in there and that arthritis can limit your shoulder. It may not be frozen from the aspect that it's a, your, a postmenopausal female telling some of these 70-year-old guys that they postmenopausal females'cause their shoulder's stiff. They don't like that very much. So it's typically the arthritis that could probably create that stiffness. So that's what I would tell those folks. Practitioners out there for shoulder stuff. I would say if you, I always, in all the talks that I've given, I always try to teach people, provoke the pathology, and as you mentioned early on, you know, all the names out there, the, the Hawkins near test or the job test those tests were designed to provoke. The pathology, let's put the tendon where it's gonna be pinched and then ask the patient to do something. And that's what doctors are good at, right? You know, it's, does it hurt here? And you put your finger on there and they go, ow. And then of course we go right back to doing it right again. So that's, that's what we're, we're trained to do. Provoke the pathology and you can then start to figure out what their pain generator is and we can treat it appropriately. And a good physical, and it starts with a good physical exam, really does.

Kerry:

Yeah, that's, that's really good. Advice and yes, the physical exam, which might be challenging is definitely one of the important things with the, the shoulder. Yeah, I think you gave us a lot of like symptoms and things like that. I would probably say those are kind of like the red flag ones where you might need to stop and see a shoulder specialist would, is that, would you agree with that?

Robert:

Sure. And, and you know, they don't always have to come to us right away. You know, they can always. You know, call the, I we're happy to see anybody. You can always call, but I know insurances are sometimes funny and they need authorizations or referrals before you can get in and things like that. So we're happy to talk it through patients and check their insurances or, or, you know, if they wanna come see their primary care physician, like your patients see you and then, you know, if it's one of those, hey, he said, throw you in therapy, we're gonna do that. And then if you don't get better, we're gonna sing it up to him.'cause you know, he's, he's got all the. Fancy toys there that can figure it out. And so, and, and we can certainly help out with that, but we're happy to see'em right away. We're, we don't, you know, we don't need to have a patient come to see us that's already been in therapy, already has three MRIs, two injections, that's totally unnecessary. We can take care of all of that. We started at the very beginning, or we see second opinions, we see revisions, things like that too.

Kerry:

Okay. And where can people find you if they wanna work with you?

Robert:

Probably the easiest way is just to go to the website, coastal shoulder.com, and from there they can, you know, see where we're located. They can send a an appointment request through the, through the app, through the email. They can get the phone number from there. And just give us a call. We actually have live people here working through answer the phones, so it's a lot easier to get through. You'll, you'll get somebody answering the phone. Devin or Kelly. And they'll, they're, they're real good. They do a good job. We got a good crew here and we just like to do the right thing, get people in, they'll, they'll be happy they came.

Kerry:

Awesome. Yes. Well, I'm so excited to connect with you and thank you so much for sharing all your wisdom with us today. I don't know if you have any last words, but we will otherwise close it for that.

Robert:

No, but I appreciate the opportunity to. Thanks so much and get healthy tampa Bay.

Kerry:

I love it. All right? Yes. Get healthy Tampa Bay. Thank you, Dr. Beau.

Robert:

You're welcome.

Kerry:

next week for everybody listening. Bye.

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Dr. Kerry Reller

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