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Transcript

Neely Quinn: Welcome to the Training Beta podcast, where I talk with climbers and trainers about how we can get a little better at our favorite sport. I’m your host, Neely Quinn, and today we’re on episode 56 where I talk with my surgeon – actually, my shoulder surgeon – Doctor Tom Hackett, who is also the surgeon who did my husband’s – both of his – shoulders. He’s done several of our friends’ shoulders so he’s kind of a popular guy around here.

He is really good at what he does. He’s also had a lot of specific training in shoulders and elbows and so he’s a specialist in shoulders, elbows, and knees. He has different techniques than some of the more conventional doctors, which is part of why I wanted to talk with him today, to sort of answer some questions. We get a lot now, actually, from you guys who are having shoulder issues and wondering what their next steps should be, wondering what their shoulder recovery is going to be after they have surgery, and wondering about the different options for surgeons and for different surgeries.

Hopefully this will answer some of those questions for you guys. We also talk about the most common injuries that he sees and the other ways of dealing with those injuries besides just surgery. Again, hopefully this will be helpful for you guys. It was really cool talking to him on this level.

I was a little nervous, not going to lie. He is my doctor and I hold him in really high regard. He fixed me so far so I have a lot of respect for him.

Before I get into the interview I want to let you know that my favorite chalk company is Friction Labs. They’re giving you guys some really great discounts, so if you go to www.frictionlabs.com/trainingbeta you’ll find those discounts there. My personal favorite is their Unicorn Dust blend. It’s soft and very fine and it coats your hands really well. Again, www.frictionlabs.com/trainingbeta and you can find their stuff there.

A little update on me. I am taking a break right now from climbing. I injured my wrist and I’ll climb this weekend, in a few days, but I’ve taken the last week off. I think it was really good for me and actually, I think I was overtraining a little bit and I was very, very tired. It’s felt good to do almost nothing for a little while. That’s something that I come across from a lot of people who ask me to be their nutritionist. They’re tired and they’re fatigued and a lot of times it just comes down to they’re doing too much and not eating enough. If that sounds like you and you’ve been training a whole lot, maybe it’s time for a break. Maybe just a few days, even.

So anyway, that’s me and I’ll get into this interview now with Tom Hackett. Enjoy!

 

Neely Quinn: Alright, welcome to the show Doctor Hackett. Thank you very, very much for being here.

 

Doctor Tom Hackett: Thanks, Neely. I’m happy to oblige.

 

Neely Quinn: Yeah. Luckily, I haven’t seen you in a while

[laughs]. For us, that is a good thing. You are our surgeon for our shoulders. Can you tell me a little about yourself and what you do?

 

Doctor Tom Hackett: Yeah, sure. I’m an orthopedic surgeon. I specialize in shoulder and elbow surgery and knee surgery. I work at the Steadman Clinic in Vail, Colorado. I specialize in athletes and sports medicine, so that means doing medical school and orthopedic surgery residency and additional subspecialty training just in working with athletes. That’s sort of evolved into working with Olympic athletes and professional teams.

I’ve worked with multiple NBA teams and Major League Baseball teams, football teams, professional athletes from all manners and walks of sports, and then I’ve really sort of sub-specialized in the last 15 years in more, like, action sports and extreme type sports.

I was a climber myself and so I’ve really had kind of a niche specialty in the climbing community, working with orthopedic injuries. That’s kind of a nutshell of what I’m doing now.

 

Neely Quinn: So you work with a lot of ‘overhead’ athletes.

 

Doctor Tom Hackett: Yeah, absolutely, a lot of overhead athletes from multiple, different disciplines and they’re all sort of very unique in many ways in regards to the stresses on their shoulders or their bodies. There’s a lot of overlap in certain athletes, too.

 

Neely Quinn: So when you say that you work with all of these teams, what are you doing? Are you following them around making sure they don’t fall? [laughs]

 

Doctor Tom Hackett: Yeah, sometimes. I mean, a lot of what I do is in the field, so sometimes it means, for example, going to spring training in the early spring with baseball teams and doing physicals and checking out guys. When they bring on new athletes I kind of vet them to make sure there’s nothing worrisome before a team signs a gigantic, million-dollar contract.

Some of it’s in the field and some of it’s with Olympic athletes. I usually go to the Olympic games and I’m there on the sidelines. Part of what I do is immediate trauma and triaging, and then that folds into some of my own personal background in wilderness medicine.

Part of it is just being a resource for those athletes or those teams so that when they do get injured, they can call. Sometimes I can handle stuff over the phone or Skype or Facetime, or whatever, and when things get bad, they/typically people will fly to Vail or drive to Vail to come for their definitive treatment.

 

Neely Quinn: Got it. Okay, so let’s talk about climbers for a little bit since that’s who my audience is. What do you see are the most common injuries with climbers?

 

Doctor Tom Hackett: So for me, it’s usually overuse injuries. If we split them into traumatic injuries, where somebody usually has a wipe-out or a fall, versus overuse injuries, which are kind of attritional things that build-up over time, I usually see more of those wear-and-tear, over time type injuries in climbers. That definitely is the shoulder and that happens to be my sub-specialty.

I see a fair amount of elbows, too. I don’t really do much hand surgery. I have a partner who does hand surgery and he sees some hand injuries in climbers but really there’s a lot of shoulder injuries that I see. It usually involves either the labrum or the rotator cuff of the shoulder.

 

Neely Quinn: Can you explain what the labrum and the rotator cuff in the shoulder are?

 

Doctor Tom Hackett: Yeah, so the anatomy is really important. The shoulder is like a ball and socket type joint and the rotator cuff is a tendon. The labrum is a type of specialized cartilage, so the labrum – ‘labrum’ in Latin means ‘lip’ and it’s like a lip or a gasket, a bumper of tissue that forms a circle that goes all the way around the socket. It adds depth to the socket, basically. It helps create a seal, it gives the socket more depth which in turn gives the joint more stability, and then, in turn, it acts as an anchor point for the biceps tendon, the long head of the biceps.

The labrum is attached to the socket and that’s very commonly injured. Then the other thing we mentioned was the rotator cuff. The rotator cuff is a tendon, and it’s a common tendon that’s made up of contributions from four other tendons that are attached to muscles called the subscapularis, the supraspinatus, the infraspinatus, and the teres minor. Those are four muscles that have their own tendons that come and blend together to make this one big common tendon, and that’s what really gives you power and control in the mid ranges of flexion with your arm kind of part way over your head. They’re not big muscles but they’re very, very important for shoulder control and especially for climbing, in the higher levels of climbing.

 

Neely Quinn: Okay, so that was a lot of anatomy. Really great work there. When you say tendon I imagine this long, skinny thing like we have in our fingers or our arms, but I think that when we’re talking about the rotator cuff it’s this big/it’s sort of like a big mass, right? Or is it one big long thing?

 

Doctor Tom Hackett: Well, that’s very accurate, what you said. A tendon, technically, is the thing that allows a muscle to attach itself to a bone. The tendon is the interface between a muscle and a bone and you’re right. Most tendons are these long, silvery, tubular-type structures, but the rotator cuff is – it’s called a cuff like the cuff on a shirt because it is a broad, flat, wide tendon, and a common tendon with a lot of interaction between four separate tendons coming together.

It’s kind of one of the more complicated tendons in the body, in terms of anatomy.

 

Neely Quinn: Is it in the back of the shoulder or the front of the shoulder?

 

Doctor Tom Hackett: All the way around the top, so it starts in the front with the subscapularis then it goes all the way over the top and it ends up in the back. It’s deep within the shoulder, right on top of the ball and socket joint. It attaches to your humerus, the arm bone, and is also intimately associated with the deltoid muscle which it’s kind of touching a lot of the time. A lot of the time, people will get pain in their deltoid or down lower at the insertion of the deltoid, which is referred from the rotator cuff.

 

Neely Quinn: I want to get into the surgical aspect of this stuff but I want to ask you a few questions before that. First of all, climbers get a lot of shoulder pain and I think that one of the biggest questions people have is, “How do I know if I should go to a doctor? How do I know if I am a surgical candidate?”

At what point should people go see someone like you when they have shoulder pain?

 

Doctor Tom Hackett: Well I think you should come and see someone if you have shoulder pain that’s just lingering and not going away despite all your best efforts, whatever they may be, you know? If you have shoulder pain for a couple of days I would probably wait it out but if it starts getting into a few weeks or if it starts to interfere with your quality of athleticism and if you can’t climb or if you have to drop down a couple of grades and you can’t do the moves that you want to make, then it’s probably worth it to see somebody. A lot of times it doesn’t necessarily need to involve surgery.

I think it’s better to go in earlier rather than later because some of these surgical procedures could be prevented, you know, if it’s addressed early on.

 

Neely Quinn: And how would they be prevented?

 

Doctor Tom Hackett: Usually with changing some training regimens, strengthening other parts of the shoulder. A lot of the wear and tear that happens to the rotator cuff is happening because of overload, because of weakness in other parts of the shoulder. For example, when you raise your arm over your head, like half of that is coming from the ball and socket part of the joint and the other half is coming from your shoulder blade articulating with your ribcage, so a lot of shoulder motion and power, and strength and control, comes from the shoulder blade, not really from the joint itself.

Doing muscular work, strengthening work, muscle activation type things on the shoulder blade and the muscles that attach to that is critical. A fun little fact is that there are 19 little muscles that attach to your shoulder blade. Like, that go up into your neck, down your spine, down towards your hip. They’re all over the place so there’s a lot of muscles that you can work on to try to improve shoulder function that you wouldn’t even think are shoulder muscles.

 

Neely Quinn: When I came into you and I had shoulder pain you basically said to me, “Okay, yes – the MRI says that you have a torn labrum. Neely, that doesn’t necessarily mean that you need surgery so I’m going to tell you to go get physical therapy.” Is that the kind of thing that you would do for most people? To help strengthen all those muscles?

 

Doctor Tom Hackett: Yeah, that’s often times the way we start out, because there’s many people that have a torn labrum that really have no problems from it. The labrum itself is not necessarily the culprit in shoulder pain and in fact, it’s really a red herring a lot of times. People/doctors that aren’t that familiar with climbers will get an MRI and they see a torn labrum, and then they all of a sudden want to pull the trigger on fixing someone’s labrum because it’s torn. When, in actual fact, the labrum isn’t really the problem.

The labrum doesn’t always hold up to the loads that the labrum sees with climbing so it’s commonly injured, but it’s not always the source of the problem. A lot of times I’ll try to treat somebody without surgery first, by trying to get them into the right kind of rehab program.

 

Neely Quinn: And then, when I went to you, you were like the third surgeon that I went to. Thank god I went to you but the first couple were like, “Yep, you’ve got a SLAP tear,” which – can you actually explain what a SLAP tear is really quick?

 

Doctor Tom Hackett: Sure, sure. SLAP stands for superior labrum anterior posterior, so what that means is it’s the superior, or upper part of the labrum. If you think about it like a clock face, it means it’s like from 9:00-3:00 and up. That would be the upper part of the labrum. It means anterior posterior because it goes from front to back. That includes the area where the biceps tendon attaches to it.

SLAP tears are very common in overhead athletes. Really common. A lot of surgeons see that and they just want to fix them but that’s not always the right thing to do in terms of operating on it, putting anchors into it, and sewing it back down.

 

Neely Quinn: Right, so that’s what I was going to say. The first surgeons were like, “Okay, well obviously what we need to do is put anchors in that labrum,” which basically is like sewing it back together, right?

 

Doctor Tom Hackett: Yeah.

 

Neely Quinn: But when I went to you, you were like, “No, that’s not how we do things around here.” Can you explain the difference of what you do and what other doctors do and why?

 

Doctor Tom Hackett: Yeah, for sure. Basically, the SLAP tears are not that different from a technical standpoint to fix, so a lot of surgeons tend to fix them. We’ve learned over the years that it’s not always the right thing to do because it prolongs the rehab, so you get more atrophy and less appropriate motion of your shoulder. There’s a lot of chronic pain that occurs and our orthopedic community nationwide has learned this over the years. Ten or 15 years ago there were like a million SLAP tears being done and everybody that came in with a labral tear got a SLAP repair.

Over the last 5-10 years or more the rest of the shoulder community of orthopedic surgeons has learned that there’s really probably more harm than good associated with repairing these SLAP tears because of chronic pain people get, and stiffness and scarring. I sort of picked-up on this very early on, fortunately, along with some other surgeons around the country that take care of a lot of overhead athletes. We started treating these SLAP tears by trimming and <unclear> them and then removing the deforming force, or the part of the shoulder that’s tugging on these SLAP tears all the time, which is the biceps tendon, then dealing with that separately. We’ve had tremendous success with that.

 

Neely Quinn: I mean, it’s still pretty common, it seems like, for other surgeons. It seems like a lot of surgeons haven’t caught on to this.

 

Doctor Tom Hackett: No, a lot of them haven’t. Without boring you to death on the intricacies of our orthopedic world, surgeons in general that are general orthopedic surgeons do a lot more SLAP repairs than surgeons who are shoulder specialists. I mean, guys who do a lot of shoulders don’t do that many SLAP tears in a year – SLAP repairs, rather.

Don’t get me wrong. I do repair some SLAP tears sometimes and sometimes that’s the right thing to do but you have to be very cautious with higher end, overhead, elite level athletes. They’re a different breed of patient than a linebacker on a football team or, you know – pick a sport – a skier or a tennis player. It’s different on a super high end climber or on a high end, elite baseball pitcher, or a high end, elite volleyball player, you know? Those athletes have to be treated differently.

 

Neely Quinn: Yeah, I remember when Seth was having his first surgery where – I think he had/it’s called a Bankart Lesion?

 

Doctor Tom Hackett: Uh huh.

 

Neely Quinn: So that’s a different kind of tear in the labrum. I remember you were very concerned about not – I don’t know how to say it – making it too tight. Putting it together so that it was so tight he couldn’t do certain movements. Is that right?

 

Doctor Tom Hackett: Exactly. That’s where, in my world, I really am sports-specific when it comes to the intricacies of the technical aspects of the surgical repair. For example, if Seth had been an NHL player and he’s a defensive man on the hockey team, I would have taken a 5-6mm extra amount of tissue that I tied up with the labrum when I tied it down, whereas being a super high end climber like Seth is, I can’t afford to have his motion or function restricted in anyway, even by two or three degrees. I don’t take as big a bite of that tissue. I don’t bunch up as much of the tissue when I’m reattaching the labrum.

That’s really where the art of shoulder surgery comes into play.

 

Neely Quinn: Okay, I want to go back to the tenodesis part of things. Instead of repairing SLAP tears what you do is, in layman’s terms, you take the biceps tendon off of the labrum and reattach it onto the arm bone, right? In layman’s terms?

 

Doctor Tom Hackett: Yeah, pretty much. It sounds kind of drastic but it’s not really. Essentially what you do is that you’re removing what we call the ‘deforming force’ on the labrum. The biceps tendon, the long head of the biceps, comes in, attaches to the labrum, and it tugs on it all the time. If you’ve got a tear underneath that area where the tendon is tugging on, it’s irritating that tear all the time. If you remove the tensile force of that tug, then the labrum doesn’t get stressed and the labrum is happy and it’s fine, you know?

What we do is we remove the long head of the biceps. There’s also, by the way, a tendon called the short head of the biceps that we leave totally alone and that’s kind of a more important portion of the biceps. That gets left alone. This one half of the biceps gets one section removed from it and then it gets tacked down about an inch away, downstream, from where it used to be. That’s called a ‘bicep tenodesis,’ which basically means reattaching a tendon. It’s been very, very successful.

 

Neely Quinn: That’s what I had done and every day now I wish that I didn’t have a biceps tendon attached to my other shoulder because it is what gives me the most pain. Are there any long term issues with having that procedure done?

 

Doctor Tom Hackett: Yeah, a great question. None that we know of, certainly not in terms of the function of the biceps. By moving it an inch or two away from where it once was we really haven’t seen any issues in the function of the shoulder/the mobility of the shoulder.

We’ve done biomechanical research on this in our lab here in Vail. I recently just queried all of the biceps tenodesis patients I had done that were done in isolation, kind of like yours. People that had it done without a rotator cuff repair or without a labral repair or without a tightening of the shoulder. Essentially, I took out all the patients I had done it on that had some kind of more heavy duty surgery associated with it and I looked at just the patients that I did the tenodesis on. I pulled 150 of those patients that had a least a three or four year follow-up and only two of them had problems with it out of 100 –  I think it was almost 160 patients.

It’s a very, very successful surgery. Really, as far as we know, it has no downside in the future.

 

Neely Quinn: Is there any evidence of there being less strength in that arm?

 

Doctor Tom Hackett: No, no, not that we know of. Not at all. There’s another procedure called a ‘bicep tenotomy’ which means, basically, clipping or cutting the biceps and then not reattaching it, and that’s very commonly done in a lot of other countries, probably more so than in the US. It’s commonly done here, too, by a lot of people. That has very minimal changes in strength, too, so you can lose a little bit of what’s called ‘supination strength’ which is like turning a screwdriver motion. That’s called supination, and flexion in the arm really has little to no change with that, so…no. You can adjust the biceps and really have no problems in the future.

 

Neely Quinn: I’m just going to take a break here for a moment and let you know a little bit more about Friction Labs, which is my favorite chalk company by far, no questions asked. Like I said, I love their Unicorn Dust blend because it really sticks to your hands longer and it really coats your whole hand.

They also have chalk balls now, in case your gym doesn’t allow loose chalk or you just prefer a chalk ball. It’s a reusable chalk ball and they also have Climbskin, which is a sort of salve/lotion for your skin that a lot of people are taking a liking to. That company also created a file that’s nice and it’s reusable and I’ve been using it all the time, actually.

They have some new stuff, and if you haven’t tried their chalk you can find it at www.frictionlabs.com/trainingbeta, but also at pretty much any REI and a lot of climbing gyms around the country. Check it out for yourself. You can get discounts for yourself at that website that I mentioned, www.frictionlabs.com/trainingbeta . They’re being super generous over there. Check it out, and I hope you like it as much as I do.

Alright, back to the interview.

 

Neely Quinn: So then, if people are – I think a lot of people who are listening to this probably have shoulder problems or they’re kind of/maybe wondering if they need to get surgery. One of the biggest things that I was concerned about was when would I be able to climb again. And when would I actually be back where I was before?

Can you go through the kinds of different surgeries and what the recovery time is?

 

Doctor Tom Hackett: Sure. A lot of what I call a ‘climber shoulder’/somebody that comes in with shoulder pain, a lot of times I see partial tears of the rotator cuff but not full tears, so I don’t have to sew them, partial tears of the labrum and partial tears of the biceps and a handful of other things like bone spurs and such.

If I’m just going in to take care of that stuff, to kind of trim and buff and taper and then address the biceps, you know, the initial recovery from that involves just a couple of days in a sling and immediate active range of motion, and within a few weeks we’re working on really getting the muscles going again. By six weeks we’re really starting to stress those muscles more aggressively, and usually within a couple of months – let’s say eight weeks, maybe 12 weeks – as long as I didn’t have to sew and repair things, it’s just the arthroscopic portion of that procedure, by 8-12 weeks we’re getting people on, let’s say, low end top roping and a little bit of plastic in the gym. Then ramping up sequentially from there with higher grades of climbing with more stress.

That could be within a couple of months, 2-3 months, to get started but it might realistically be 3, 4, 5, even six months before you’re climbing 5.12 or higher 5.13s and up, but if I have to sew the cuff, if I have to start reattaching the labrum, if I have to start tightening things up, then that timeline gets elongated a little bit.

 

Neely Quinn: And what kinds of timelines are you looking at then?

 

Doctor Tom Hackett: You’re probably kind of doubling that timeline, so the people where I have to sew the rotator cuff – which I’ve done a lot of elite level climbers, where the cuff was torn so badly I actually had to reattach it back to the bone – you’re looking at maybe more like 4-5 months before you’re doing low grade climbing, more like just to get some fresh air and socialization and getting your fingers beat up again. It’s just easy, easy climbing at 4-5 months and then at 6-7 you’re starting to ramp up through the grades again and then by 8-9, you’re cranking, essentially.

 

Neely Quinn: As opposed to what I had done, where I was in a sling for just a day or something, those people are in a sling for how long?

 

Doctor Tom Hackett: They might be in a sling for about three or four weeks, you know? Fortunately, our techniques have really evolved so from a mechanical standpoint our ability to reattach a tendon to the bone, mechanically, has gotten better and better. That allows – if you get a really good repair, then you get into an early motion and that’s what’s exciting about shoulder surgery athletes. As the future evolves, we can fix things better so that they can move it faster so that you get less atrophy and less dyskinesis of the muscles. That’s really/it’s super bomber, what we’re doing now.

The future of that, to take it to another level, is to improve the biologic environment. We’re doing experiments on things like platelet-rich plasma and stem cells and other ways to biologically improve the environment of healing so that things get better faster. Ultimately, the whole goal is to get people moving quickly.

 

Neely Quinn: So you are doing stuff with stem cells now?

 

Doctor Tom Hackett: Yeah, yeah. We’re experimenting with it. In the shoulder, in fact, there’s no data to support its use at this time with stem cells or plasma or platelets or things like that. We’re actively doing a lot of stem cell research, trying to figure out a way to get them to work.

Stem cells are essentially your body’s cells that can turn into anything and help in any part of the body, whether that’s your tendon or your bone or your bladder – whatever. What we’ve found, though, is that they need to be coaxed into turning into whatever you want them to turn into, which means taking them out of your body and then adding something to them, usually some type of growth factor, and then reintroducing them into the place that they need to go.

Right now in the US you’re not allowed to do that. You have to go to like Germany or Mexico to be able to add growth factors in. Right now, all we can do is take them out, process them – you know, spin them down – and put them right back in without any type of manipulation.

 

Neely Quinn: Is there research being done in Germany or Mexico or anything on that?

 

Doctor Tom Hackett: Yeah, yeah there is. There’s a lot of research being done on stem cells right now but, you know, it’s kind of like this shotgun approach where there’s no precision at all yet on the use of stem cells at this stage. You’re just kind of tossing them in there and hoping they do what you want them to do.

 

Neely Quinn: Have you seen them, anecdotally/clinically, do what you want them to do?

 

Doctor Tom Hackett: In the shoulder, not yet. There’s some promising research with some cartilage restoration but not really with tendons in the shoulder like what we were talking about with the labrum and with the rotator cuff. Nothing yet, but we’re hopeful and we’re chipping away at it.

 

Neely Quinn: When I came in for surgery, one of the biggest reasons that I didn’t want to do surgery was because I was terrified. I, first of all, didn’t want to die due to anesthesia and second of all, I didn’t want anything to go wrong with the surgery and possibly end up like – actually, one of my friends just had shoulder surgery. I think it was very similar to what I had, and her surgeon was terrible. I don’t know what he did but she no longer has use of her hand at all, and he severed some nerves or something.

I’m wondering if you could talk of the risk of that happening. How high that is, why that might happen, and any other risks of surgery.

 

Doctor Tom Hackett: My God. That is an awful story. That is also very unusual with shoulder surgery. Most shoulder surgeries are really not risky. There are definitely some surgeries that I do that I’m gripped the whole time, because of working around some proximity to a critical nerve or a blood vessel or something, but with the type of surgeries we’re talking about that’s highly unlikely.

You can put risks of surgery into two batches. One batch is like risks that happen with any surgery, like an infection or a blood clot, and that’s highly unlikely with most arthroscopic surgery. If anybody was listening to this, you’d want to find somebody who’s in a facility who does a lot of these types of surgeries and a facility that has a really good track record with infections, like, some hospitals have a higher infection rate than others and it’s definitely worth it to ask what that is.

Where I am in Vail we’re very fortunate to have a very low infection rate, partly because of altitude. At 9,000 feet almost, there aren’t that many people that can live up here that aren’t that healthy, so therefore here we have a lot of really healthy patients because we don’t have a lot of people with really bad diabetes or heart disease or lung disease and kidney disease. Those are the people that tend to carry worse bacteria, because they can’t handle the altitude. Anyway, that’s a sidebar, but it’s worth it to look into the infection rate of any hospital you might be going to.

Those are the things that can happen with any surgery, like an appendectomy or something like that. Then there are specific risks that are associated with surgeries in the shoulder and this stuff that we’re talking about. There are a couple of nerves you have to be careful of but if you go to someone that does a lot of shoulder surgery, that risk should really be mitigated to a fairly low level.

 

Neely Quinn: When I had my surgery done, I came back in the next day. I didn’t take enough medication because I’m an idiot so I had searing, searing nerve pain, like – it was awful and it lasted, honestly, it lasted for weeks. When I talked to you about it, I was an outlier. It was very rare for you to see what you were seeing with me.

What do you think could have happened with me to cause that?

 

Doctor Tom Hackett: That’s true. That’s really unusual. It can be pretty painful for a day or two but really weird to have, like, searing nerve pain. First of all, it’s hard to know. Secondly, the nerves that kind of come out of the neck and go down past the shoulder were numbed-up as part of your anesthesia from your surgery and that could have contributed to it.

There’s something called the ‘brachial plexus,’ which is a bunch of nerves that all run by the shoulder and there’s something called a ‘brachial plexopathy’ which is an irritation of those nerves. It sometimes just doesn’t make sense, in terms of the distribution of where those nerves are on fire or why it happened. There’s definitely some things that happen in the human body that we can’t explain sometimes, but yeah, that’s super unusual for that to happen.

 

Neely Quinn: Yeah, I think you did say it was probably from the nerve block, the needle just going into the nerves, but – and this isn’t to say that if I could do it over again, I would absolutely do it over again. My shoulder is absolutely amazing now and I don’t really have the nerve stuff at this point. I just wanted to bring it up because it is a possibility. I mean, anything can happen, but both Seth and I would say we would both do these surgeries over again.

What kinds of questions can you actually ask a surgeon to find out if they are, in fact, a shoulder specialist and that they’re a good one?

 

Doctor Tom Hackett: I mean, it’s hard to know sometimes but it’s always worth it. These are the things I would ask: 1) do you take care of a lot of climbers, like, do you know what climbing is? Do you know what I mean? It’s helpful sometimes to go to a surgeon that is familiar with the sport that you’re doing. It’s not just a sport, it’s a passion. It’s a way of life. It’s a reason for getting up out of bed every morning. It’s important to go to somebody, I think, that understands what your passion is. You want to ask them that.

Probably more importantly is to say, “Hey – how many of these have you done? Do you have a very high success rate? What’s your complication rate?” You might feel a little nervous asking someone that but it’s your body. It’s worth it to ask them. Anybody that gets offended by that, I’d run away from.

Then the next thing that’s worth asking is, “You know, I was wondering about getting a second opinion. Is there somebody that you think would be good?” For me, personally, I encourage people to get second opinions. I’m like, “Yeah, go. I’d love to hear what somebody else has to say about this.” I think if you ever ask a doctor about maybe getting a second opinion and they maybe get weird about it, I’d run in the other direction.

Just to summarize that, ask them, “How many of these do you do? What’s your success rate? Is there anybody else you think I might talk to about this?” If you feel comfortable with you doctor you don’t necessarily need to go and take the time and money expense to see someone else, but it’s worth asking, potentially.

 

Neely Quinn: Do you think it’s worth asking them if they know what/if they would do a tenodesis? Like, to see if they’re…

 

Doctor Tom Hackett: Yeah, you just say, “Hey. Okay, I got an MRI. It shows that I’ve got this big SLAP tear/labral repair and I’ve got a little irritation in my cuff.” You’re like, “What do you think is better? Repairing this labrum or doing a tenodesis?” There’s a gigantic body of literature out there on that particular subject that, in the last 4-5 years, has come out on different types of athletes, different types of age brackets, gender, everything, so that’s something a shoulder specialist should be very familiar with.

 

Neely Quinn: Right, because I think a lot of them don’t do them and don’t even know what it is, or something.

 

Doctor Tom Hackett: Or they don’t like it, or they’re not comfortable with it or something. And, by the way, there’s a lot of different ways of doing a tenodesis. You want to ask them, “How do you do it? Where do you put it?” and just get – these days you’ve got to be an informed consumer for your health care.

 

Neely Quinn: I think that’s actually what happened with my friend who lost the use of her hand. He did the tenodesis under her arm or something instead of in the back of the shoulder or wherever you did it. Is that something that could cause that? Like, he went through all of those nerves.

 

Doctor Tom Hackett: Yeah, that is just really weird for that to happen. I’d love to know what happened in that case because it’s very unusual for that to happen. Something odd went down in that surgery.

 

Neely Quinn: Okay. I would like to actually talk just a little bit about elbow stuff. Is there anything/do you see a lot of climbers for elbow stuff?

 

Doctor Tom Hackett: I see some but nowhere near the volume for shoulders because it’s just less common to have elbow problems, but I definitely see people for it. It’s usually arthritis. You can kind of – in the elbow, it’s more common to have arthritis as opposed to the shoulder, where it’s really less common to have arthritis. Arthritis is damage to cartilage, essentially. The elbow is a little more susceptible to getting beat on, you know, with repetitive dynos and hanging all the time on it.

There’s any number of different particular moves in climbing that stress the elbow cartilage, so arthritis is probably one of the more common things I see with climbers. Then the other thing would be some overuse stuff, which is tendonitis like what people refer to as ‘tennis elbow’ or ‘golfer’s elbow,’ which has nothing to do with tennis or golf but is just the common way of saying medial or lateral epicondylitis, which is an overuse problem on the tendons either on the medial or the lateral side of your elbow. It’s kind of those two things: arthritis or tendonitis.

 

Neely Quinn: So with elbows, what do you do for those things in surgery?

 

Doctor Tom Hackett: We try to avoid surgery on the tendons around the elbow as much as possible. There’s all manner of things you can do to try to dodge surgery, but when it does come to surgery it usually means going into that tendon and removing the portion of the tendon that is unhealthy and then reattaching the healthy part back to where it belongs. That’s a simple way of saying a repair of either the medial or lateral epicondyle tendon.

For people with arthritis, the arthritic elbows usually do really well with an arthroscopic approach to remove debris and kind of buff and clean the cartilage that’s rough and then release the capsule, which is the lining of the elbow, which gets really tight.

Guys that have been climbing especially for 20, 30, 40 years often times have what we call a ‘flexion contracture’ of the elbow, which means it won’t straighten out all the way. That becomes really hard to rest. If your elbow will only straighten out – like, it won’t go fully straight, it will go like 20 or 30 degrees shy of straight, then anytime you try to hang on it to rest your muscles are firing the whole time.

You need to be able to have a super straight elbow to be able to rest and then you just have a little bit of grip strength that’s going on, but you can rest the rest of your shoulder and arm musculature. If it’s bent and you can’t straighten it then you can never rest, so fatigue is a big issue, especially with doing big multi pitch climbs and stuff, or working projects or whatever.

I have an arthroscopic approach where I can actually remove a lot of that scar tissue, and that’s a very successful surgery and it doesn’t have much down time associated with it. You start moving it right away and a couple months later you’re climbing again. That’s a good surgery.

 

Neely Quinn: That is a good surgery. It’s weird. I don’t really hear about anybody having elbow surgery. Oh wait – maybe one for bone spurs. One of my friends just had – is that a common thing to see?

 

Doctor Tom Hackett: Yeah, bone spurs come up with arthritis. They’re kind of like the downstream effect of arthritis so just from – that’s what I was getting at, taking those bone spurs out is really helpful and not a bad surgery to go through.

 

Neely Quinn: Actually, speaking of bone spurs – I just have a couple of questions left for you. When we first met you were like, “Yeah, you have this tear in your labrum. It’s not really that big of a deal. You might have a little bit of a bone spur in there, according to the x-ray,” and that’s what another orthopedic doc said, too. Then, when you went in there you actually found that I had a pretty big bone spur and the bone spur was really affecting my biceps tendon. I guess my question is: can you talk a little more about bone spurs and also, what can you really see from an MRI and x-rays, and how different is it when you actually get in there?

 

Doctor Tom Hackett: Always different. You can get burned by MRIs. Usually MRIs over call things. They’re getting so sensitive these days that they’ll oftentimes show things that look worse on an MRI than they really are in real life. It’s very uncommon to have it be the opposite, like to have a normal MRI and to go in and see something that’s torn. That’s pretty weird for that to happen.

X-rays show bones really well but don’t show any soft tissue structures like tendons or ligaments or stuff so they’re kind of limited in value. Nevertheless, it’s better than nothing.

Bone spurs are also very common. Like, 15% or more of the population have bone spurs on the undersurface of their chromium, which is the bone on top of your rotator cuff that gets spurs. They don’t always bother people. Just because you see a spur doesn’t always mean it automatically has to come out, you know? Those spurs build-up over time. There’s a little ligament there called the ‘coracoacromial ligament’ that attaches to that part of the bone and just tugs on the bone a million times during your lifetime. That stress of the ligament tugging on the bone in conjunction with some other stresses stimulate the bone to grow more bone a little bit. Then it overgrows and it gets a little hook on it and that starts digging on your rotator cuff and it’s this vicious cycle. We basically trim those spurs out and that subsequently gives your rotator cuff more room to move around in without getting pinched or without rubbing. You can usually see those on an MRI or x-ray.

 

Neely Quinn: Yeah, it was just weird because the first doctor I went to was like, “No, you’re fine. You don’t have a problem,” just from the x-ray. I remember being like, “No, I definitely have a problem. You need to do an MRI.” I kind of had to force her to do it. What do you think about that? I’m sure that other people have experienced that.

 

Doctor Tom Hackett: Yeah, I think, and without me going off on our health system too much, you need to push sometimes for yourself and advocate for yourself with your physicians. I wouldn’t worry about being pushy. Just say, “Hey. I want to get an MRI,” because you’ll get information from it that can be useful, and at the very least you’ll get a point of data along a curve that you can compare to in the future. You get another MRI a couple of years later and you can see if things have progressed, but a lot of doctors are reluctant to get MRIs and a lot of insurance companies don’t want to pay for them.

If you shop around – listen, if you’re going to buy a new rope/you want a new 11mm rope or whatever, you’re going to shop around a little bit to find the best price on it and to find the brand you want. You do a tons of research on where you’re going to get your new rope. Is it going to be a dry rope or what? You go into a lot of details on it and people don’t do that with MRIs and they should, because if you shop around a little bit for an MRI you’ll find out, “Oh, guess what? Some MRIs are better than others and some are more powerful than others and some give more resolution and some are a lot cheaper than others.” For example, there’s an MRI not far from here in Colorado that charges almost $3,800 to get an MRI and you can get one in another location less than two hours away for $300 that’s a better quality MRI. It’s worth it to shop around a little bit.

 

Neely Quinn: It’s just hard for us to know what questions to ask these MRI companies.

 

Doctor Tom Hackett: But it’s worth it to just ask them. Think of your MRI like a product you’re buying that you’re spending your money on. You want to just shop around a little bit. It’s worth it to do it. You could save a lot of money and you can get a better quality scan. Sometimes people come in with MRIs from these open scanners and the quality is so bad it’s hard for you to even really, actually, make any good decisions, you know?

 

Neely Quinn: So you were talking about advocating for your own health and I think that this is a question that a lot of people have. They’ll email me now and be like, “Look – I could get surgery or I couldn’t get surgery. I can still climb but how should I know if I should get surgery?”

Even with me, at the very last appointment with you, you were like, “You don’t need surgery, Neely. You don’t actually – this isn’t a huge problem.” I couldn’t climb. It hurt so much to climb so finally I was just like, “Well, I’d just rather do the surgery and take the risk than never be able to climb again.”

What do you think should help people make that final decision?

 

Doctor Tom Hackett: That’s a totally, very personal decision. There are some things that happen in the shoulder in climbers that you have to get fixed. If you’ve got a big, giant tear of your rotator cuff and it’s not attached or if your shoulder is dislocating, for example, and it’s popping in and out, you need to get those fixed. That’s not an option. You have to get that fixed. You can’t be, like, climbing Fitzroy and have your shoulder pop out. You’ll be screwed, you know? There are certain times that it’s just better to get things fixed.

There are other times, with more wear and tear type injuries, that it gets a little more personal. You have to say, “What is the value of my ability to take my climbing to the level I want it to be at?” For some people, if they’re happy climbing 5.10 and they’re able to take some days off, then they might be able to get by just doing some therapy and a little injection every once in awhile or something. If you’re trying to project your way up to a much more elite level of climbing and you can’t do that because your shoulder’s hurting and there’s a potential solution for it, I’d say do it.

That then becomes a very personal question. You have to look at yourself in the mirror and decide how important that level of athletic performance is to you and then you have to have that conversation with your surgeon to say, “Hey man, like, do you think you can get me to where I want to be? What are the good odds for me to be able to get this better?”

 

Neely Quinn: That’s good advice. I have one last question for you and this is about your potential new research. I remember it was really interesting to me when you said – I think you said 70% of overhead athletes have labral tears, or something? Some very high number, but a lot of people don’t ever have pain from it. Can you talk a little bit more about that and what your new research is?

 

Doctor Tom Hackett: Right. In a lot of overhead athletes the labrum is commonly torn. There are different types of tears and different degrees, and there’s a whole spectrum on it. Those labral tears can be/some of them need to be fixed and a lot of them don’t need to be fixed. Even ones that are big tears aren’t necessarily causing pain so you have to really investigate other areas of the shoulder that are causing pain, like the rotator cuff or problems with your scapula, or whatever. There’s a whole differential list of problems.

One of the areas of research that has been explored in several other sports that deal with overhead athletes is identifying what’s normal in someone’s shoulder that does this particular sport. That really hasn’t been explored in climbing so I’m kind of pretty far down the road on exploring that avenue. So far, I’ve gotten what’s called an ‘IRB’ which is an Institutional Review Board, which basically is that people say it’s okay to do some kind of project on people. That’s a gigantic process and a huge pain, but I’ve gotten through that and I actually just got funding for it.

What I’m going to do is set-up shop with an MRI scanner and put as many elite and high level climbers through it as possible. These are going to be climbers that don’t have pain in their shoulder/that haven’t had surgery in their shoulder and there’s a whole questionnaire and vetting process that goes on. Then imagine if I had 100 MRIs on 100 male and female athletes that are super high end climbers that have never had shoulder pain and don’t have shoulder pain now, and of those 100 climbers 50, 60, 70% of them have labral tears. That would be really good information to have, to say, “Hey, guess what? It’s common for climbers to have labral tears and have no pain with it. Don’t get fooled by the labrum. Don’t get fooled by these partial rotator cuff tears. They don’t necessarily cause pain.”

I’m hoping to garnish this information and then share that with the orthopedic community so that, hopefully, there are more surgeons out there that are better informed that will hopefully do less surgery on people that may not necessarily need it. That’s the goal of the research.

 

Neely Quinn: So the goal would be to do less surgery and more…what? How would you help people?

 

Doctor Tom Hackett: More rehab, or at least for surgeons to take that step towards evaluating other ways to treat someone short of a trip to the operating room. That might be physical therapy, that might be rolfing, that might be dry needling, that might be medications, that might be injections, it might be – there’s any number of different options – modifying training, you know, we didn’t really get into that too much. There’s a lot of ways to modify training to minimize stress on the shoulder.

It’s sort of, at least, getting surgeons to walk down that road of potentially looking at nonoperative treatment, at least as a first line of defense.

 

Neely Quinn: That’s so interesting that you’re a surgeon, a successful surgeon, advocating for fewer surgeries.

 

Doctor Tom Hackett: Neely, I love doing surgery. I can’t wait till I get up in the morning and go operate on someone. That’s what I love to do but I only want to bring someone to the operating room that really, really, really needs to be there because A) I’ve found out/the main thing is that those patients do better. Your results are superb. You get better results as a surgeon if you only bring people to the operating room that really need to be there, then you take a surgical strike and you go after a specific target. You know what? People get better.

 

Neely Quinn: If you do this research – I don’t know if you’ll do it but – somebody will possibly come to my climbing gym with a portable MRI machine and be doing MRIs on people?

 

Doctor Tom Hackett: Yeah, that’s the plan. I’ve been in discussion with a couple of different people involved in a couple of different gyms and other people and vendors and leaders within the climbing community to try to pull this off. The funding is a big thing because it’s not cheap to drive a giant MRI machine, which is on a semi and needs a massive generator to power it, and rent that for a week, so it’s a lot of logistics involved. It’s going to go.

 

Neely Quinn: Cool. Nice. Last question: you just mentioned a bunch of different alternative therapies to help shoulders. Can you tell me what you’ve seen your patients have success with outside of surgery and PT?

 

Doctor Tom Hackett: Outside of PT? Definitely I’ve seen some really good results in and around the shoulder with acupuncture. I’ve also seen – more so than in other parts of the body, doing acupuncture for your ankle or your knee. I’ve seen quite the same results as I have with the shoulder. I don’t know why that is, but it is. I usually kind of encourage people to consider acupuncture as an avenue.

Then, I’ve seen also a lot of results with muscle activation therapy, which is a kind of way of getting muscles to get turned on that haven’t been working properly. Because there are so many other muscles associated with shoulder motion, that can be very successful, too. Especially in the back, in the thoracic spine and neck and stuff like that has been very helpful.

I don’t know. I’m totally open for people trying to find anything but those are probably the two that I’ve seen the most results with: muscle activation therapy and acupuncture.

 

Neely Quinn: That’s helpful. Cool! Well, I really, really appreciate this. This has been good, for me, to talk to you and hopefully a lot of people will take something away from this. Thank you, very, very much.

 

Doctor Tom Hackett: I hope so. It’s a real passion for me and it’s a way for me to kind of stay connected to a lot of my friends in the climbing community, which I don’t get to be quite the same/be part of at the same level that I used to be a part of so it’s really fun for me, you know? I have a lot of passion for it.

 

Neely Quinn: Yeah. Good! Well, do you ever get out climbing anymore?

 

Doctor Tom Hackett: I do, yeah! I go out. I try to get out a couple times a year. I like going out to the desert and getting on some towers and stuff so, yeah, I try to do some but it’s nothing like back in the old days. [laughs]

 

Neely Quinn: Just out of curiosity, what were the old days? Where did you climb?

 

Doctor Tom Hackett: I spent a lot of years in the Colorado Springs and Boulder area, and did some guiding in Eldorado and stuff, and then spent a lot of years in Jackson. It was a ton of alpine climbing in and around the Tetons and then I climbed around the world a little bit, too, over the years. Then, actually, I was getting ready for a trip to Cho Oyu and broke my leg in a giant whipper that I took. I still have that #2 Friend on my mantlepiece, because that thing saved me.

 

Neely Quinn: Oh my god!

 

Doctor Tom Hackett: This giant whipper broke my leg and I didn’t end up going on that trip and I ended up making the decision through that experience to go to medical school.

 

Neely Quinn: Oh! Woah! I didn’t know that. That’s pretty cool.

 

Doctor Tom Hackett: It was a pretty big deal to make that transition from climbing to studying. [laughs] It happened through an injury.

 

Neely Quinn: Yeah, it so often does. That’s a cool story. Well, thank you Doctor Hackett.

 

Doctor Tom Hackett: Yeah, it’s my pleasure, Neely. Hopefully I’ll get to see you again, maybe on the rock rather than in my office.

 

Neely Quinn: Yeah, that would be great. Okay, have a good one.

 

Doctor Tom Hackett: Thanks. Bye.

 

Neely Quinn: Alright. I hope you enjoyed that interview with Doctor Hackett. If you have shoulder issues I hope it was educational in some way. If you don’t have shoulder issues I hope it was a really good reminder to do your shoulder exercises, keep your shoulders strong, don’t overdo it, and all that good stuff.

If you want to learn more about Doctor Hackett, you can go to his website, www.doctorhackett.com and it shows more about his bio and how you can be a patient of his, if you want. Just a reminder, we were in Boulder when we had our shoulder surgeries so we drove to Vail, but he also works out of Frisco, which is a much shorter distance from the Boulder or Denver area.

I mentioned this on a previous episode, that Doctor Hackett was actually featured on tv for being one of the most beautiful male doctors in the country. I have that clip up on the episode page if you want to check it out. You can also Google it. It was on the show ‘The Doctors,’ and it’s pretty cool to see him on tv. So anyway, that is Doctor Hackett.

If you need help with your training and you’re still not exactly where you want to be with your climbing – who is? You can use some of our training programs. If you’re a route climber we have our ‘route climbing’ training program, which gives you three unique workouts every week. You go in six-week cycles, so you’re training different things every six weeks. Power endurance, strength, finger strength, sometimes you have projecting cycles where you’re just kind of seeing where you’re at, and all of those contain shoulder stability work so you’re constantly working on your shoulders to strengthen them, strengthen your rotator cuff, strengthen everything to keep everything safe in there.

If you’re a boulderer, same thing. We have a bouldering training program where you get, again, three workouts every week and they’re unique. Same thing, you have six-week cycles but we focus on things that are more pertaining to bouldering. More power/power endurance and there’s also always shoulder strengthening in there, as well.

You can find those on www.trainingbeta.com. I think that’s it for today. Thanks very much for listening and I will talk to you next week. Have a great week!

 

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