By: Andrew F. Rocca, M.D.
Do you experience shoulder pain performing everyday tasks such as vacuuming and lifting? If so, you may have a rotator cuff tear. Rotator cuff tears are a common source of shoulder pain in adults. They are most frequently injuries from wear, rather than trauma. Our busy lives and everyday activities take their toll on our tendons, ligaments, and joints over time. Consequently, as our bodies age, we become more prone to these wear-type injuries. If you are suffering from shoulder pain, a rotator cuff tear may be the problem.
The pain from a rotator cuff tear may develop suddenly or over time—in the beginning it may be noticed only with overhead activities such as reaching or lifting. At first, you may find relief by resting your shoulder or taking Motrin or aspirin. Over time, however, the pain may become noticeable even when you rest. You may also experience stiffness and loss of motion. Rotator cuff tears are more common in your dominant arm and can be present in the opposite shoulder even if there is no pain. These tears are often seen in individuals who perform frequent overhead activities such as construction work or painting. Certain athletes, such as swimmers, pitchers and tennis players also seem to be at increased risk. Unlike the slow progression of the wear injury, when the tear occurs traumatically there may be sudden acute pain, a snapping sensation, or even an immediate weakness of the arm.
The rotator cuff itself is an intricate part of the complex shoulder anatomy that allows the shoulder to move in many directions. It is made up of four tendons—supraspinatus, infraspinatus, teres minor, and subscapularis—and their muscle units. These tendons combine to form a “cuff” over the upper end of the arm. The muscles originate from the shoulder blade and form a single tendon that helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint.
Your orthopaedic surgeon can help you determine if you might have a rotator cuff tear based on a combination of your symptoms, examination, and special tests such as radiographs or MRI. During the exam, the doctor will look at your shoulder for areas of tenderness or to see if there is a deformity. He or she will also measure the range of motion of your shoulder in several different directions and test the strength of the arm. The doctor will also check for instability and problems with another part of your shoulder called the AC (acromioclavicular) joint. The doctor may also examine your neck to make sure that your pain is not coming from a pinched nerve in your cervical spine and to rule out other conditions such as arthritis.
Plain X-rays of a shoulder with a rotator cuff tear are usually normal or show a small spur. For this reason, your doctor may order an additional study called a MRI (magnetic resonance imaging). This test better visualizes soft tissue structures such as the rotator cuff tendon. A MRI can also help to distinguish between a full thickness (complete) tear of the tendon and a partial tear. It can show the doctor where the tear is located and how much of the cuff is involved. Once a diagnosis of rotator cuff tear has been made, your orthopaedic surgeon will recommend the most effective treatment.
Treatment for a rotator cuff tear can be operative or non-operative. In many instances non-surgical treatment can provide pain relief and can improve the function of your shoulder. Non-operative treatment may include rest and limited overhead activity, use of a sling, anti-inflammatory medications such as Motrin or Aleve, steroid injections, and/or physical therapy. It may take several weeks or months to restore strength and mobility to your shoulder and then only approximately 50% of patients will obtain satisfactory relief with this type of treatment. Given this fact, the treatment you select will probably be based on a thorough discussion with your doctor regarding the overall advantages and disadvantages in your specific case. Some of the most obvious advantages of non-operative care include the fact that you may avoid surgery and its inherent risks, such as infection, stiffness, and anesthesia complications. In addition you may have less “down time.” The disadvantages, on the other hand, are strength does not improve, tears may increase in size over time, and you may need to decrease your activity level.
If non-operative management is selected, a multimodal program, which often progresses to include supervised physical therapy, will most likely be initiated. Ultimately, however, if non-operative treatment does not relieve your symptoms your orthopaedic surgeon may recommend surgery. Surgical management is recommended for rotator cuff tears that do not respond to conservative management and/or are associated with weakness, loss of function, and limited motion. Because there is no evidence of better results in early versus delayed repairs, many surgeons consider a trial of non-operative management to be appropriate. Surgery may also be considered if the tear is acute and painful, if it is the dominant arm of an active individual, or if you need maximum strength in your arm for overhead work or sports.
The type of surgery performed depends on the size, shape, and location of the tear. A partial tear may require only a trimming or smoothing procedure called a debridement. A complete tear within the substance of the tendon is repaired by suturing the two sides of the tendon. If the tendon is torn from its insertion on the humerus, it can be repaired directly to bone. Sometimes a combination of procedures is also appropriate. In the operating room, your surgeon may also remove part of the front portion of the scapula, the acromion, as part of the procedure. The acromion and the spurs that form in this area are thought to cause impingement on the tendon. This may lead to a tear. Other conditions, such as arthritis of the AC joint, or tearing of the biceps tendon may also be addressed at the same time.
Operative treatment of a completely torn rotator is Designed to repair the tendon back to the humeral head (ball of joint) from where it is torn. This can be accomplished in a number of ways. Each of the methods available has its own pros and cons; all have the same goal–getting the tendon to heal to the bone. The three commonly employed surgical techniques for rotator cuff repair are open surgical repair, mini-open repair, and arthroscopic repair. The overall complication rate following rotator cuff surgery is estimated to be about 10 percent. The most frequent complication is tendon retearing, followed by joint stiffness, deltoid detachment (which can be avoided by arthroscopic techniques), nerve injury, and infection.
The choice of surgical technique depends upon several factors including the surgeon’s experience and familiarity with a particular procedure, the size of the tear, patient anatomy, quality of the patient’s bone and tendon tissue, and the patient’s needs. Regardless of the repair method used, each repair type shows similar levels of pain relief, strength improvement, and patient satisfaction. Many surgical repairs can be done on an outpatient basis. A brief overview of the most common methods used for repair of the rotator cuff follows.
Open Repair. Open repair is performed without arthroscopy. The surgeon makes an incision over the shoulder and detaches a portion of the deltoid muscle to gain access to and improve visualization of the torn rotator cuff. Through this approach, the surgeon can also remove bone spurs from the undersurface of the acromion–a procedure known as acromioplasty. The incision is typically several centimeters long.
All-arthroscopic Repair. A fiber optic scope and small instruments are inserted through small puncture wounds instead of an open incision. The scope is connected to a monitor and the surgeon performs the repair under video control. This technique uses multiple small incisions (portals) and arthroscopic technology to visualize and repair the rotator cuff. The acromioplasty is also performed arthroscopically. All-arthroscopic repair is usually an outpatient procedure.
Mini-Open Repair. As the name implies, mini-open repair is a smaller version of the open technique, but not entirely performed arthroscopically. This technique does incorporate arthroscopy to visualize the tear and treat damage to other structures within the joint, such as with the all-arthroscopic approach, however, once the arthroscopic portion of the procedure is completed, the surgeon proceeds to the mini-open incision to repair the rotator cuff itself.
Regardless of which procedure is performed, the arm is immobilized after surgery to allow the tear to heal. Therapy then typically progresses in stages. Initially, the repair needs to be protected until adequate healing of the tendon to bone occurs. For this reason, most patients use a sling for the first four to six weeks after surgery and are instructed to limit active use of the arm during this period. Passive range-of-motion exercises are begun with a therapist. Progressive strengthening and range of motion exercises continue during the next six to 12 weeks. Most patients have a functional range of motion and adequate strength by four to six months after surgery. A strong commitment to rehabilitation is important to achieve a good surgical outcome. The doctor will advise you when it is safe to return to overhead work and sports activity.
In summary, rotator cuff tears can be a source of pain in the shoulder and their incidence increases with patient age. Initial treatment is often non-operative and can result in decreased pain and improvements in range of motion; however, strength will not be recovered. Surgical repair results in pain reduction and improved function and strength in more than 80 percent of patients. Three primary methods of repair are available and include open surgery, all-arthroscopic techniques, and the mini-open approach. Each technique has similar results in terms of satisfactory relief of pain, improvement in function, and patient satisfaction, although less invasive surgery frequently results in an easier rehabilitation process and less postoperative pain. In addition, certain factors have been identified that can decrease the likelihood of obtaining a satisfactory result, regardless of the type of procedure, and include poor tissue quality, large or massive tears, advanced patient age, and poor compliance with post-operative rehabilitation and restrictions. Ultimately, however, management decisions for how best to treat your shoulder are a personal decision involving many factors that are best discussed on a case-by-case basis with your orthopaedic surgeon.