Rotator cuff tears are one of the most common shoulder injuries. More than 2 million patients seek help for rotator cuff injuries every year. The good news is a majority of rotator cuff tears DO NOT need surgery. A good orthopedic surgeon will recommend appropriate nonoperative treatment for rotator cuff injuries, and understands when to recommend surgery for rotator cuff tears. Below is the evidence based approach I take to treating rotator cuff tears.
What is the rotator cuff?
Courtesy of orthoinfo.aaos.orgThe rotator cuff are a group of muscles that help move the shoulder around in space. These muscles work in conjunction with many other muscles around the shoulder blade to help produce shoulder movement. A lubricating sac called the bursa is sandwiched between the rotator cuff and the bone on top of your shoulder (acromion). A healthy bursa facilitates smooth gliding of rotator cuff tendons when the arm is moved. For effective shoulder functioning, ideally, all 4 rotator cuff muscles work together in synchronization. If any one of the four muscles are not working optimally, other surrounding muscles must work in overdrive to make up for the lack of function.
I often compare the 4 rotator cuff muscles to the 4 engines on an airplane. For the airplane to fly well all 4 engines must be working. If one engine breaks down, the plane may still fly, but it puts increased stress on the other 3 engines. If 2 engines breakdown, depending on which 2 fail, the plane may not be able to fly at all!
When treating rotator cuff problems, the question becomes- Does the engine just need a tuneup? Does the engine need a jump start? Or does the engine need a complete repair?
How do you diagnose rotator cuff tears?
The evaluation for a rotator cuff injury begins with a thorough history of the symptoms. Rotator cuff injuries can occur after an acute trauma involving the shoulder or slow and progressively over time. Distinguishing between acute and chronic rotator cuff injuries is important for guiding treatment. The most common complaints with rotator cuff injuries include pain when reaching overhead, pain when reaching for an object out in front of the body, pain when reaching behind their back, and/or pain when laying on their shoulder at night. Pain with radiation to the elbow or the neck is common since muscles around the shoulder are overworked compensating for rotator cuff dysfunction. If shoulder pain radiates past the elbow it could suggest problems with nerves around the shoulder. Shoulder symptoms can be produced by irritation of the nerves as they exit the spine in the neck region. Distinguishing features of shoulder pain originating from nerve irritation at the neck include accompanying signs of numbness, tingling, or hand weakness on the side with shoulder pain.
A focused physical exam of the shoulder is performed next. Physical exam maneuvers to test individual rotator cuff muscles are used. Certain provocative tests evaluate for areas of inflammation in the shoulder. As a part of the work up, X-rays are obtained next to establish if there are any predisposing anatomical risk factors such as a bone spur or shoulder malalignment that correlate with rotator cuff injury. If there is a high suspicion of neck problems cervical spine X-rays may also be obtained. This is often all the information needed to arrive at a diagnosis. MRI is only necessary when a chronic rotator cuff injury has not responded to standard non-operative treatment (described below) or if acute rotator cuff tears from trauma are suspected.
Chronic degenerative rotator cuff tears
Chronic and degenerative rotator cuff tears are secondary to cumulative wear and tear of the rotator cuff muscles and generally begins to affect people after the age of 45. The rotator cuff tendons pass below a bony area (the acromnion) before they attach to the upper part of the arm bone. Rotator cuff tendonitis, or impingement syndrome, describes the inflammation and fraying of the tendons over time with shoulder movement. Symptoms from rotator cuff tendonitis usually begin insidiously and can progress over time, to the point where even activities of daily living like brushing ones teeth or combing hair can be difficult. Common causes of rotator cuff tendinitis include:
- Occupations such as hairstyling or painting overhead that require maintaining the arm elevated at the shoulder for prolonged period of times
- Playing overhead sports that involve repetitive stressful shoulder movements such as tennis, baseball, volleybally, swimming, or overhead weight lifting
- Poor coordination of the shoulder blade and shoulder muscles including poor posture
Rotator cuff injury represents a continuum of pathology. Early rotator cuff injury may only involve irritation in a part of the tendon experienced as pain during very specific movements. With time this inflammation may affect the neighboring lubricating sac called the bursa (see diagram above) sandwiched between the rotator cuff and the bone on top of your shoulder (acromion). When the rotator cuff tendons are injured and the bursa becomes involved it is called a bursitis and aggravates shoulder dysfunction. Prolonged chronic rotator cuff irritation can lead to muscle attrition and progress eventually to rotator cuff tears. Tears that only involve a part of the muscle’s tendon are considered partial tears. When the entire tendon detaches from the bone, the tear is considered complete. As the injury increases in severity, compensation from neck or shoulder blade muscles can generate referred pain.
Treatment of all chronic rotator cuff tears begin with non-operative management. This includes activity modification, physical therapy, anti-inflammatories, and an adjunct steroid injection in the right circumstances.
Activity Modification. Overhead activities place greater demand on the rotator cuff muscles than others. Occupational activities such as painting overhead or carpentry that require repetitive hoisting and elevation of the shoulders are stressful for shoulders with rotator cuff tendinitis. Finding ways to minimize these overhead motions are one strategy for coping with rotator cuff tendinitis. This may be as simple as incorporating a brush extension for painting overhead, or using ladders or stools when appropriate. Certain sports can be more taxing on the shoulders. Activities such as tennis or volleyball have several repetitive overhead motions that can aggravate rotator cuff tendinitis. ears
Physical Therapy. The rationale for physical therapy is often questioned by patients, especially in those that are active and fit. It is important to remember that there are several muscles that help with shoulder movement. Most shoulder exercises recruit a number of muscles that compensate for a weaker rotator cuff muscle. Consequently, strong supporting muscles get stronger, and the weak injured rotator cuff muscle often remains neglected getting weaker. In a focused physical therapy rehabilitation program, emphasis is placed on the weakest link, and exercises are tailored to isolate the involved rotator cuff muscle. Returning to the analogy of airplane engines discussed above, when one engine (i.e. one rotator cuff muscle) is compromised, the other engines have to work in overdrive to keep the plane flying. Physical therapy is equivalent to getting a jump start and tune up for the dysfunctional engine. While it may seem counter-intuitive to many, the prescribed therapy involves very low weight and rather an emphasis on form to isolate certain muscles in the shoulder. Generally 4 weeks of therapy across 8 sessions are necessary to begin seeing results. The importance of therapy cannot be stressed enough. Even though it can be time consuming and an inconvenience with a busy work-life schedule, failing to “tune-up the engine” is going to precipitate more problems over time. Much like a car with neglected maintenance, what may start as a minor problem, can progress to a critical problem in the future if ignored.
Anti-inflammatories. This class of drugs (referred to as non-steroidal anti-inflammatory drugs or NSAIDs), can help manage the symptoms from a degenerative rotator cuff injury. While the analgesic affect of these drugs maybe immediate, I often counsel patients they need to take it for a sustained period (2-3 weeks) to realize the anti-inflammatory benefits. As long as there are no health concerns such as drug allergy, kidney problems, or drug interactions, I recommend patients try a course of Meloxicam, Ibuprofen, or Naproxen to see if it helps manage their symptoms.
Steroid injections. If the pain and shoulder dysfunction has progressed to the point that oral medications are inadequate and therapy participation is limited by pain, a steroid injection into the space above the rotator cuff muscles into the bursae may be very helpful. A steroid injection is one way to “put the fire out” and help stem some of the inflammation. It is important to understand however that this is only a short term solution, and must be combined with physical therapy to prevent weak rotator cuff muscles from falling into a cycle of inflammation and irritation.
Non-operative treatment is the mainstay for chronic degenerative rotator cuff injuries. Even in the setting of full-thickness complete chronic rotator cuff tears, greater than 85% of patients undergoing non-operative rehabilitation treatment experience a lasting improvement and benefit and do not need surgery. If all the measures above fail, in refractory cases with persistent unbearable pain, I obtain an MRI to characterize the extent of the rotator cuff injury, and then accordingly, if a tear is identified, offer arthroscopic rotator cuff surgery. Arthroscopic shoulder surgery is discussed in detail further below.
Acute traumatic rotator cuff tears
Courtesy of orthoinfo.aaos.orgAcute traumatic tears are usually the result of a significant force transmitted across the arm. Some common scenarios include falls onto an outstretched arm or falls from a bike directly onto the shoulder. Unlike chronic tears that usually result from deteriorating muscle tendon tissue, an acute tear involves healthy rotator cuff tendons that are avulsed from the bone. The clinical presentation of these injuries is more dramatic with sudden inability to raise the arm. When an acute rotator cuff tear is suspected, MRI is not delayed. Once the extent of the injury has been characterized, any complete tears involving retraction of the torn avulsed tendon can benefit from arthroscopic rotator cuff repair. Surgery generally should be performed in this setting sooner rather than later before muscle atrophy begins to develop.
Arthroscopic rotator cuff repair
Arthroscopic surgery of the shoulder is commonly performed in the United States. The procedure involves inserting a camera about the size of a pen into the shoulder joint. From another incision, I insert specialized arthroscopic tools to manipulate structures inside the shoulder. In older patients, with chronic degenerative rotator cuff injury, as described above, surgery is the last resort. In contrast, for patients with acute traumatic rotator cuff tears, arthroscopic surgery is considered immediately.
During arthroscopic surgery the torn tendon is identified, and cleaned of any debris. The tendon is then pulled back to where it anatomically connects with the shoulder bone. Using specialized implants that resemble sheet rock anchors with attached sutures, the tendon is sutured back onto the bone. It is notuncommon to use 1-3 anchors to securely reattach the tendon to the bone. If preoperative imaging identified any factors predisposing rotator cuff injury such as a bone spur, these can also be addressed at the time of rotator cuff repair.
Rotator cuff tear secured with suture anchorsFor the appropriately selected patient, arthroscopic rotator cuff repair can provide significant reduction in pain and improvement in shoulder function/strength. Recovery from a rotator cuff repair can be challenging. Initially the involved arm has to be immobilized for 6 weeks in a bulky and cumbersome shoulder brace while the muscles heal in their new position. This can significantly impact your independence and ability to function after surgery. After the period of immobilization, 3-4 months of physical therapy is necessary to reduce the shoulder stiffness and re-strengthen the rotator cuff muscles that have not been used since surgery. That is, the “engines” need a jump start to get going again. Depending on the extent of the injury, recovery continues for anywhere from six months to a year after surgery. Overall, after recovery is complete , the outcomes are good-excellent.
Learn more about the arthroscopic shoulder surgeries I perform or call 281-690-4678 now to schedule a consultation to discuss your shoulder problem.
Sources:
http://www.ncbi.nlm.nih.gov/pubmed/23540577http://orthoinfo.aaos.org/topic.cfm?topic=A00064http://www.orthoguidelines.org/topic?id=1007