'Behind the Blue' with Orthopaedic Surgeon, Researcher and Advocate Dr. Carolyn Hettrich

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From the campus of the University of Kentucky, you're listening to Behind the Blue. 

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Kody Kiser: Slowly but surely, springtime is returning to the Bluegrass. As people head back outdoors for yard work, and seasonal sports like baseball start up once again, shoulder injuries will be on the rise. Dr. Carolyn Hettrich is an Associate Professor of Orthopedic Surgery in the University of Kentucky Department of Orthopedic Surgery and Sports Medicine. A shoulder and elbow specialist, Dr. Hettrich treats many of those injuries. 

I'm Kody Kiser with UK PR and Marketing, and I'm joined this week by my colleague Olivia Ramirez. On this week's episode of Behind the Blue, Dr. Hettrich joins us to discuss why she chose sports medicine, her work leading the world's largest study on shoulder instability, how she advocates for improved treatment and funding for muscular-skeletal injuries, and more. 

Kody Kiser: Dr. Carolyn Hettrich is our guest this week on Behind the Blue. Thank you very much for being with us. Dr. Hettrich, you are part of the, correct me if I get this wrong, you're part of the UK Orthopedics and Sports Medicine program. What is your title exactly? 

Carolyn Hettrich: I am an Associate Professor here and primarily focus on sports medicine and shoulder and elbow injuries. 

Kody Kiser: You also work with UK Athletics in some form and function? 

Carolyn Hettrich: Correct. We collaboratively take care of all of the athletic teams. I focus primarily on the Olympic sports, but I do help out my colleagues with some of their other sports as well. 

Kody Kiser: Well tell us a little bit about how you ended up here at the University of Kentucky. You are originally from Portland, is that correct?

Carolyn Hettrich: Correct. I was born and raised in Portland, Oregon, and did my undergraduate training at Palomar College. Which is just outside of Los Angeles. Went from there to the University of Washington in Seattle. Decided at that point in time to move to New York for residency, where I spent six years. After New York, I moved to Nashville, where I spent a year in fellowship at Vanderbilt. And then moved to Iowa, where I did my first six and a half years of my career. And then just recently moved here to Kentucky. 

Kody Kiser: That is a lot of crisscrossing the country. 

Carolyn Hettrich: Correct. 

Kody Kiser: Is that - were those just the opportunities that you wanted to go for, or for particular areas that you wanted - places you wanted to be? Or how did...? 

Carolyn Hettrich: Sure. I've never been regionally specific. I've always wanted to go where I felt there was the best, either educational or training, opportunity or the best job. So, I've always been open to living out anywhere, and have gone to where I felt I would get the best training. 

Kody Kiser: So how did that - you're in Iowa, and then you come here. How did that take place? What was it about UK specifically, or Lexington, or Kentucky that brought you here? 

Carolyn Hettrich: Well, University of Kentucky has fantastic people on staff who I was very interested in potentially collaborating with. And after working with Dr. Latterman and Dr. Johnson over the years, and getting to know them through national meetings and conferences, it became clear that there might be an opportunity for my work and my research here at University of Kentucky, and so decided to make the move. 

Olivia Ramirez: Can you tell us a little bit more about the type of research that you do?

Carolyn Hettrich: So my research is all focused around the shoulder. I do several different types of research. I do basic science research focused on tendon to bone healing. And also looking at ways to design implants for shoulder replacements so that they are more robust and they don't wear out as easily and don't have as many complications. 

I also do clinical research where I run a multi-center trial for shoulder instability with Brian Wolf out of Iowa. And we've now recruited over a thousand patients into that study, making it the largest one in the world, currently. 

Olivia Ramirez: And so, most people might think, oh, shoulder injuries, that's going to be more common in swimmers, and baseball players. But how common is it in the general population? 

Carolyn Hettrich: It's very common. And different injuries can go with different age groups and different activities. Things like shoulder instability and shoulder pain are very common in young athletes. And that's exactly right; swimming, tennis players, volleyball athletes, football players have shoulder and elbow injuries. As people age, rotator cuff injuries tend to be more common in people between 40s and 60s. And then, in the older decades of life, shoulder arthritis becomes more common. So you see a different kind of spectrum of activities throughout the different age ranges. 

Kody Kiser: It does seem - I don't think a lot of people realize, or maybe they just don't think about it. It seems like shoulder and maybe hip, there's such a wide area - range of motion that you get out of it without even thinking sometimes. I know a lot of people might do some type of work, or some type of workout, where they think I didn't realize I had muscles there that became sore. And I think sometimes we do actions that we don't even think about - repetitive motion types of things. Is it - comparatively I mean, how difficult is it sometimes to treat injuries because of that range of motion and that level of mobility? 

Carolyn Hettrich: So, you're correct. The shoulder is the most unrestrained joint in the human body, meaning it has the most motion in the most directions. That makes it the most prone to dislocation. It has the highest incidence of dislocations of all the major joints. It gives you all the motion that you know that you can do. So you can throw, and you can do all your activities of daily living. But, because it doesn't have much bony constraint, or it's kind of like a golf ball on a golf tee, it relies a lot on balance. So that's balance of the capsule, balance of the muscles - both in terms of flexibility and in terms of strength. And so, the shoulder, because of that, is much more complex than some of the other joints in the body, which don't rely on that balance. So a lot of things aren't as easy as just, you know, fixing a broken bone, or fixing a torn tendon or a torn ligament. You really have to look at the rehabilitation afterwards to make sure that that balance is restored to give people a pain-free joint. 

Olivia Ramirez: So you mentioned, you know, the rehabilitation after. When you're working with athletes who want to return to play, what - I guess, how does treatment maybe differ? 

Carolyn Hettrich: So when looking athletes who want to return to play, I think it's important to 1) to try to quantitatively assess how that athlete is doing. So, you know, to look at their strength as compared to their other arm or their other leg, to see if you can get a baseline of what their strength is supposed to look at. A lot of these athletes are so strong that if I, for example, if I test their strength, it seems like they're super strong to me, but if you test it as compared to their contralateral limb, you can see that they actually have some significant strength deficits.

So for me, for return to sport testing, I like to make sure people have the strength testing, and different types of strength testing, usually also looking at kind of balance and speed and endurance. And there's a way to quantify that. I think the other important thing for athletes returning to play, is that with some injuries it's just a traumatic event, and it's a random thing and you can't necessarily prevent that from happening again. But with a lot of injuries, it's not a traumatic event. It's an overuse injury. And that's usually based on people either lacking that balance within their joint beforehand, or of having improper technique. And because of that, I think it's also important to try to address why they had that injury in the first place, to keep them from having a repeat injury down the road. 

Kody Kiser: Is there a - we'd kind of talked about this before - before today. The idea that we're at a time now where spring training for a lot of sports are happening, but also a lot of people are starting to shake the cold off. It's spring, and weather is starting to change a little bit. We're going to get outside more, whether we're going to have some sort of workout outside or we're going to do yard work or garden or whatever we might do. Are there times of year where we start seeing more incidents of these types of injuries? 

Carolyn Hettrich: That's correct. So you'll start to - as people start playing baseball again, you'll see more baseball injuries. That's exactly right. Overuse injuries in people who are more middle-aged. You might see a lot more of these gardening injuries of people going out and breaking up their gardens, or farmers starting to, you know, prepare their fields. In the fall, you'll see different injuries from raking leaves and doing things like that. So, I would say, definitely with each kind of change of seasons and change of activities, you'll see injuries from that. 

You'll also see injuries associated with different crazes at the time. So, for example, when Wii Fit came out, you saw a bunch of Wii Fit injuries. And when CrossFit became really popular, you started to see a lot of CrossFit injuries. So depending on the season and then depending on sort of what's the popular thing to do, you'll see increase in incidences in those things. Those sports. 

Kody Kiser: What are some things you might suggest to people that aren't specifically athletes training who might have a better kind of understanding of that and better idea of how to pace? For people who don't necessarily think in those regards, or don't think about the potential of causing those injuries, what are some things you might suggest people keep in mind?

Carolyn Hettrich: For a lot of people who, on a daily basis, might not be super active or work out a lot, when they do need - have an event coming up that is going to be more physically stressful, whether that be they're wanting to spend an entire weekend in the garden or a weekend chopping wood, or doing something like that around the house, the best thing to do is to somewhat either work towards that, or break it up. And so they can either increase their abilities slowly over time, or try to spread that out a little bit. Because if you aren't used to doing a lot, and then all of a sudden go out and spend 12 hours chopping wood, you're going to be hurting the next day. 

Olivia Ramirez: So, how did you come to choose orthopedics and sports medicine as your specialty? And then, what kind of sparked your interest in the shoulder and elbow? 

Carolyn Hettrich: I have a very similar to most - or a lot - of orthopedic surgeons. I had an injury myself when I was in high school. I had an injury to my wrist, which eventually required surgery. And I absolutely loved my orthopedic surgeon. He was kind of this grumpy old guy. And he explained things to me and let me hang out with him in his office. And I liked what he did, and then I like kind of who his patients were. You know, looking around the waiting room, it was lots of people like me at that point. I was a young high school athlete, and there was, you know, a lot of other people who wanted to kind of get back to life and get better. And so, I kept that kind of in the back of my mind. I kept having athletic injuries playing sports in college, and so kept, unfortunately, familiarizing myself with other orthopedic surgeons. 

When I went to medical school, I had a pretty good idea that that's what I wanted to do. And so I started doing research right away with the chair of orthopedics at the University of Washington. His name's Dr. Frederick Matsen. And he was an excellent mentor, and he's a shoulder surgeon. So, spent a lot of time with him and a lot of time working on different research projects. Dissecting shoulders, learning the mechanics. And have kind of been hooked on the shoulder ever since. 

Olivia Ramirez: When you got your Master's in Public Health, did you know you wanted to do Muscular-Skeletal? Like that that was one of the issues you would be focused on, or no? 

Carolyn Hettrich: I'm somebody that has a lot of interests. And so, even pre-dating medical school, I had a lot of interest in global health. And when I was in high school, did a long service trip to Mexico, and in college, did some service down in Ecuador. And so I had this global health interest. So I some interest in getting a public health degree for a long time from that. When I was in residency, I did a year long research fellowship to spend more time kind of focusing on research. And during that time, I was able to get a Master's in Public Health. So I did both things. I wanted to learn more research methodology, to make sure that I did better quality research. So that my study design would be better. That I would understand how to analyze and interpret data better. And then also was able to do some kind of course work on global work and then health policy as well. 

Olivia Ramirez: And how do you use your MPH now, combined with your MD? You do some kind of Capital Hill research days? 

Carolyn Hettrich: Correct. So I use it a lot for research. So the research methodology classes help quite a bit. The health policy aspect of things also comes - is used quite a bit as well. I don't do as much global health as I used to just due to time commitments, but have been engaged through the American Academy of Orthopedic Surgeons in doing kind of national health policy work. So working within our Academy, or with our Academy, to make sure that our patients are taken care of in the best ways possible. And oftentimes, that trying to petition for certain laws to be passed. We recently worked on a couple of sports medicine bills that dealt with taking care of athletes across state lines and being able to take appropriate medications to take care of athletes across state lines. So, taking a limited, small prescription of pain medication in case somebody gets hurt and things like that. 

And then also, working on laws that we feel are not good for our patients. So, there were certain parts of the healthcare reform bill that we felt would be better if they would be tweaked a little bit. So working on that side. So both working for things, and then also trying to get some things changed. 

Kody Kiser: That seems like sometimes, when you think about research and procuring funds for research, that sometimes that really difficult in light of being able to show some tangible kind of, easy to kind of see, result. But it seems like advocacy for patients is one of those strong things that you can use as an example. A really ready-to-go example of why you need this funding. Have you found that that's...?

Carolyn Hettrich: Correct. So we used to - or we've had in the past with our Academy was research Capital Hill Days. And it was exactly that. We're - I was able to go and take patients of mine. And you go and you visit your local congressman and senators. And the patients tell their story, and then you're able to tell the story of how your research enabled that patient to have their care and to do as well as they're doing. Last year, I took an 80 year old woman who I'd done a shoulder replacement on, and she was then able to go river rafting in California and, you know, was able to travel around the country taking care of her own bags, and taking care of her grand-kids, and traveling and kind of leading a great life. And so, them being able to see that we're actually able to use the funds that they're giving us to translate that into patient care, so that patients, you know, have cures. That they're able to get back to their activities of daily living, and they're able to get back to work, is really important. 

One of the most difficult things for a researcher, obviously, is obtaining funds and getting funding for your research. And that's particularly tough now that healthcare funding has decreased and different challenges in the economy. So that's something that we also do often, is try to make sure that people understand that funding research is what makes changes in medicine happen. It's why there's advancements and also powers a huge portion of the economy. So, trying to make sure that they do that, and that their next generation of researchers are funded is important. 

Kody Kiser: How has technology changed the type of work that goes into, I guess some of these procedures? Do you see that some of the advancements that are being made faster and faster, does that - how have you seen that change in the last few years as far as like the quality of results that you can get with patients? 

Carolyn Hettrich: I would say that technology is incredibly important. And you can see that in just about every aspect of what we do. In terms of, you know, implant design, where they now have ways to test implants better than ever before through computer modeling and computer simulations, through the actual implants themselves - they are able to make things that are actually physically stronger and that have less wear and have better wear characteristics and can last longer for patients. They also, through the use of technology, are better able to assess what our patients are doing. So we have different kinds of tools which we can use to measure motion and measure strength, and look at what they're doing. Technology is also going to play an important part in the future, especially in, you know, more disadvantaged populations. As we're going to be able to do things like physical therapy over, you know, Skype or FaceTime, and do things more remotely and able to save patients then those costs for transportation and that time off of work. And because of that, I think technology will come into play more and more. 

Kody Kiser: As far as your work goes, what's the - what are the next steps. Where do you see things for what you're doing? What's going on over the next six months, next year, next two years? 

Carolyn Hettrich: I think all of my work, the general focus is how do we make patient better, how do we make their repairs stronger, how do we make them more functional. So that they can get kind of the most out of their life moving forward, wherever that is. Whether that's a young athlete who we want to be able to get back to performing highly at sports, or whether that's an old person who we want to be able to do their activities of daily living and pick up their grandchildren. And, I think, in the next six to twelve months, we're actively working on some things here at the University of Kentucky and better understanding all the different factors that contribute to success after shoulder replacements. And we're specifically looking at the scapula, or the shoulder blade, right now. It's all part of the upper limb girdle and how the motion in that, with your scapula, may affect your results after shoulder replacement. So I think that, hopefully, we'll have a better idea in that time period. 

We're actually going to be able to start analyzing more of our data for our shoulder instability cohort. We have over 500 patients now that we have two year data on. And so we're going to be able to start processing some of that and having a better idea on what the predictors are of good outcomes after shoulder - surgery for shoulder instability. 

Olivia Ramirez: And how do you like living in Lexington and Kentucky?

Carolyn Hettrich: I think Lexington is really beautiful. Especially with the green - the green horse fields and all the trees. So, we have really enjoyed living here. We find it to be a great size of city; so it still kind of has some aspects of a small town and we're still able to live in an area where we feel a little bit, you know, isolated, but yet, you know, isn't that far for me to get to work or to go out to dinner and kind of enjoy the benefits of city life. 

Olivia Ramirez: You had mentioned when we talked when you first joined the team, that part of what interested you in coming to UK was the focus on research. Can you talk a little bit more about that? 

Carolyn Hettrich: Yes. One of the great things about the University of Kentucky was that there still is that focus on research, and there still is that focus on increasing patient care and developing that next line of researchers. That was very attractive to me when I was looking at taking the job here. And since I've started, I've definitely found that environment to be true - or that to be true. Where the environment is very supportive of research. There's excellent collaborators and the administration doesn't only say that, you know, they're interested in research, but they actually put resources to make sure that that happens. So, it's been a great place to keep building my career. 

Kody Kiser: Dr. Carolyn Hettrich, thank you very much for being with us. We appreciate it. And good luck with both the research and the patient care, and the advocacy work that you do as well. 

Carolyn Hettrich: Thank you for having me. 

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Thank you for joining us on this edition of Behind the Blue. For more information about this episode, or any other episode, visit us online at uky.edu/behindtheblue. You can send questions or comments via email to behindtheblue@uky.edu. Or tweet your questions using #behindtheblue. Behind the Blue is a joint production of University of Kentucky Public Relations and Marketing and UKHealthcare. 

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