A: The rotator cuff is a group of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor) that connect the arm to the torso. Any movement of the arm or shoulder must be balanced by the rotator cuff for the shoulder to function properly.

Shoulder cuff problems are the most common cause of shoulder pain. But the most common rotator cuff problem is not a tear but tendon damage without a full tear. This is usually treated with physical therapy and sometimes a joint injection.

An acute full-thickness tear in a person with an otherwise normal shoulder is usually treated with immediate surgery to prevent muscle atrophy and further joint degeneration. Full-thickness tears in a person with rotator cuff disease who have new limitations in shoulder movement are also usually treated surgically.

The goal of surgery is to restore as much function to the shoulder as possible, and my experience with my own patients who undergo shoulder surgery is that most function can be restored. However, it can be a long road to get there, with physical therapy and sometimes occupational therapy after surgery.

Some older patients with full-thickness tears still have fairly good shoulder function. Conservative therapy (with the same physiotherapy and occupational therapy experts) can be effective. Surgery should only be considered in people who are unresponsive to treatment and medication.

Q: A friend of my 31 year old daughter has just been diagnosed with visual snow syndrome. He is devastated, as his profession heavily depends on his ability to see clearly. I understand that the disease is not physiological but rather neurological. Is this disease incurable? Is there a genetic link? Do you know of any ongoing studies?

CS

A: Visual snow syndrome is new to me. It is a rare disorder where people notice snow-like spots throughout the visual field. It can sometimes start in childhood, and apparently there are adults who never remember having vision without these kinds of dots, which can lead to significant loss of visual acuity (and psychological consequences, like you can imagine).

A 2017 review of the condition identified this as being related to, but distinct from, migraine with aura. They came up with two treatments: a drug normally used for seizures, lamotrigine, and another used for migraine (among other conditions), verapamil. The authors noted that it does not cure the disease but can improve vision significantly enough to have a real impact on people’s lives.

A second review from 2020 suggested that drug therapy is unfortunately not effective most of the time, and it also suggested that wearing colored (blue-yellow) glasses was helpful in some people with this condition.

I found a trial in Colorado recruiting patients for transcranial magnetic stimulation for this condition. You can find it on clinicaltrials.gov.

Q: I am now 78 years old. My mother’s two brothers died of heart attacks at 55 and 65, so when I was in my 50s I had a calcium scan of my heart. Since then I have been taking atorvastatin 10mg along with blood pressure medication.

Last year I had my aortic valve replaced and an angiogram showed about 30% blockage in my coronary arteries. This makes me believe that a statin drug is a good way to prevent artery blockages. Do you think anyone with a family history of heart disease should have a scan?

RS

A: A calcium scan is a special type of x-ray that identifies calcium-containing plaque in the arteries of the heart. It is not a direct look at blockages.

It is possible to have a normal calcium score and still have blockages. Most blockages in the arteries are a combination of cholesterol and calcium plaque, but not all of them contain calcium. Also, some people have calcifications without blockages.

Doctors use specialized calculators that can help predict the risk of a coronary event over 10 years. If a person is at high enough risk to undergo treatment anyway, a calcium score is not needed to recommend treatment. A person at very low risk is unlikely to have coronary calcium, and even if they do, it doesn’t necessarily mean blockages. For those in the middle, the coronary calcium score provides useful additional information that can help a doctor decide if drug therapy is appropriate.

The joint guideline from the American Heart Association and the American College of Cardiology advises against the use of coronary calcium screening for low-risk individuals with a family history. The calculators do not take family history into account (there are also other risk factors not listed in the calculators), so a physician must exercise individual judgment. I’ve definitely ordered diagnostic tests from people who have low calculated risks but have other risks that aren’t in the calculators (like a patient of mine with a twin brother who needed bypass surgery) .

A wise doctor doesn’t make decisions based on just one risk, whether it’s cholesterol or family history. The whole person — all of their risk and protective factors, their ability to improve their lifestyle, and their tolerance to medications — must be considered before making a truly personalized recommendation.

Q: I read an article about a 92-year-old man who said he followed an exercise program that only required 10 minutes a day to stay fit. I would like to know where to find this program, because I need to get back in shape at 82 years old, after knee surgery and arthroscopic procedures.

MARYLAND

A: There is evidence that high-intensity workouts, even of short duration, can have significant benefits for cardiovascular fitness. However, this is not the kind of exercise program I would recommend for someone recovering from surgery, which is a slow, gradual process.

Muscles, connective tissue and bones slowly strengthen. It takes time to build them, and trying to do a 10-minute high-intensity workout would be a really bad idea. A physical therapist can help you design an exercise program that can help you recover from surgery and get in shape. As you become fitter cardiovascularly, as well as stronger in muscles and connective tissues, you can definitely explore more high intensity training.

Dr Roach regrets that he cannot respond to individual letters, but will incorporate them into the column whenever possible. Readers can email questions to [email protected] or send mail to 628 Virginia Drive, Orlando, FL 32803.