ROTATOR CUFF TEARS
What is the rotator cuff?
The “rotator cuff” refers to a small group of four muscles that help hold the upper arm bone (the humerus) into the socket of the shoulder blade (the scapula). The four muscles are the supraspinatus, infraspinatus, subscapularis and teres minor. The primary function of the rotator cuff is to hold the head of the humerus into the socket of the scapula while other muscles of the shoulder joint move the arm overhead.
How is the rotator cuff injured?
Rotator cuff tears occur primarily secondary to “wear and tear”. Most experts attribute rotator cuff tears to excessive rubbing of the rotator cuff against the undersurface of the bony roof of the shoulder blade (the acromion). Many of these patients have bone spurs on the acromion which contribute to the gradual “wear and tear” process.
Another common way to tear the rotator cuff is by trauma. For example, falling on an outstretched arm can cause a tear. Repetitive overuse in overhead throwing athletes or tradesmen can result in a tear.
It should be noted that rotator cuff tears are associated with long head bicep tendon ruptures, shoulder dislocations and proximal humerus fractures.
What are the signs and symptoms of a rotator cuff tear?
Rotator cuff tears occur most commonly in patients in their 50’s and 60’s. It is not a disease of 20 year old athletes, in contrast to what the media indicates. Characteristic symptoms include night pain, pain and/or limited motion, while others experience significant reductions in motion. Rotator cuff tears can be mimicked by impingement syndrome, frozen shoulder, shoulder arthritis or a nerve injury. Sometimes these entities coexist, making the diagnosis more difficult.
How is a rotator cuff tear diagnosed?
Depending on your length and type of symptoms, your orthopedic surgeon will most likely order an MRI (magnetic resonance imaging) of your shoulder which can demonstrate a tear, whether it is a partial or a complete tear. An MRI is considered the “gold standard” for confirming the diagnosis. Other diagnostic tests available are an arthrogram or an ultrasound. Talk to your orthopedic surgeon about which diagnostic test would be right for you.
Are all tears the same?
No! They can be classified as partial thickness or full thickness tears based on the amount of tendon involved. They can be classified as 1, 2, or 3 tendon tears. They can be graded based on the size of the tear: small (< 1cm), medium (1-3 cm), large (3-5 cm),, massive (>5cm).
How are rotator cuff tears treated?
Partial or small full thickness rotator cuff tears can be treated conservatively, or, non-surgically. This form of treatment includes anti-inflammatory medications, physical therapy and possibly a cortisone (steroid) injection. Studies have documented that approximately 50% of patients with rotator cuff tears will respond to conservative treatment. The decision for surgical treatment is based on your degree of discomfort and disability. Generally speaking, larger rotator cuff tears and those that do not respond to 3-6 months of conservative treatment, may be good candidates for surgical repair.
The decision to recommend surgery is based on the patient’s symptoms. Patients can display a wide range of shoulder motion depending upon the size of the tear and strength of surrounding muscles. For example someone may have normal motion with a small tear, or conversely have little active motion with a large or massive tear.
Many factors impact the decision making process. Medical co-morbidities (eg. Diabetes, heart disease, smoking, age, osteoporosis) may affect treatment recommendations. The risk of infection and postoperative shoulder stiffness is increased with diabetes. The risk of repair failure is increased in smokers. The possibility of the repair failing also increases with diminished bone density. As a generalization we are very conservative in recommendation formal rotator cuff repairs in patients over 70 years of age.
It is important to understand that we recommend surgery based on patients’ symptoms. Night pain is a classic symptom of rotator cuff tears and is by far the most common single reason why patients decide to proceed with surgical treatment.
Another important point is that just because there is an MRI abnormality consistent with a rotator cuff tear does not mean that you have to have surgical treatment. Abnormalities developing within the rotator cuff tendons is, in fact, seen with the aging process. We see patients who have rotator cuff tears who have no pain and normal motion…surgery is not recommended in these individuals.
A final point is that some patients may have long standing intermittent shoulder pain which precedes a significant increase in acute symptoms. In other words patients may have had a previous tear that has further torn. In these patients the chronicity of the tear may impact the ability to repair the tendons.
A small subset of patients may present to the office with a chronic massive tear that is longstanding and irreparable. Perhaps 2-3% may have a specific type of arthritis which can occur specific to a massive rotator cuff tear. This is called rotator cuff tear arthropathy. This difficult problem may require special treatment with a different kind of shoulder replacement procedure in which the goals of surgery are limited (pain reduction) but unfortunately motion is not greatly benefited.
How are rotator cuff tears treated surgically?
Most experienced orthopedic shoulder surgeons perform rotator cuff repairs arthroscopically, on an out-patient basis. Essentially, your surgeon will enter the shoulder joint through two or three small ¼ inch incisions (one stitch each), inspect the joint thoroughly, remove inflammed, scarred or thickened tissue (“bursa”), “shave down” the bony roof of the acromion (“acromioplasty”), identify the rotator cuff tear and repair it using a variety of sutures or anchors depending on what is appropriate for the type of tear. The typical rotator cuff repair takes 1.5-2 hours to complete.
In some situations we perform small incision (1.5-2 inches) to perform a “mini-open” procedure. This may be done in more difficult tear patterns. We have evolved away from doing formal full “open” procedures except in the most unusual situations.
What can I expect after surgery?
The procedure is performed on an outpatient basis. Patients usually have a general anesthetic with or without a scalene nerve block which helps reduce postoperative discomfort. Patients will require some postoperative pain medication for about one week postoperatively. Of note is that many patient can discern a difference in the character of their pain frequently within the first 10 days after surgery. Physical therapy begins almost immediately following surgery. For the first few days you will be performing simple home exercises consisting of range of motion activities. These are performed to minimize the chance of developing a “frozen shoulder”. Formal, outpatient physical therapy generally begins 2-3 weeks post-operatively. The first six weeks of therapy after surgery will focus on restoring range of motion. The next two to three months will focus on strengthening and restoration of shoulder function. Our typical time frame to release you to all work and recreational activities is 4-6 months post-operatively. One will gain strength for up to one year postoperatively.
In a study we published several years ago pain reduction/elimination was significantly reduced in a group of 72 patients who were evaluated at a minimum of two years postoperatively. The average age at surgery was 58. The subjective satisfaction level was extremely high. Reoperations were extremely low.
What are some of the complications associated with rotator cuff surgery?
The major concerns are 1) infection (<1%), 2) blood clots, 3) medical complications, 4) postoperative shoulder stiffness (8-10%), 5) symptomatic retears