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Other things that can be used in conjunction with shoulder rotator cuff repairs are things like patches. Patches have only been around the last decade or so, but these involve using things like cadaver skin to reinforce the repair. This is used in patients whose repairs are not strong and there’s a worry that they’re going to retear. Patches can be done arthroscopically or through an open incision, and the recovery time is typically a little bit longer just based on the size of the tear. For patients that have larger tears in their shoulder a strong recommendation is made to consider the surgery. What we know about rotator cuff muscles is that the larger they become torn, the more symptomatic people become, and the longer that it’s torn, the less likely of a chance that it can be fixed. If left untreated for many years, patients typically develop more pain and more dysfunction in reaching over their head, and if it becomes severe enough, a lot of times their only option is to consider a reverse shoulder replacement.
Patients with tears in their rotator cuff muscles usually have pain associated with overhead activity. When they have treatment in the form of surgery, it means that the surgeon has repaired the tendon back down to the bone. When this happens, patients can’t use their shoulder normally during this healing process because too much motion too quickly will compromise the integrity of the repair. People typically have to wear a sling for anywhere between three and six weeks afterwards. We know based on basic science studies that a tendon takes about six weeks to really heal back down to the bone. Once that healing has occurred, then the real therapy starts. That means you work on restoring the motion of the shoulder and regaining the strength. In general, it takes patients three to four months to fully recover from rotator cuff surgery. Larger tears can take up to six to nine months to fully recover as well.
The rotator cuff. It consists of four muscles around the shoulder. These are the Subscapularis, the supraspinatus, the infraspinatus, and the Teres minor. These four muscles around your shoulder give you the wonderful motion and rotation of your arm over your head. These are muscles do things like allow you to reach the back of your head to comb your hair, things like reaching behind you to get your wallet out of your pocket, and even things like to scratch your back. Without these muscles, it becomes very difficult to do these things. These muscles encompass the whole shoulder. The subscapularis is in front and allows you to pull objects towards your body. The supraspinatus muscle is on top of the shoulder and it allows you to lift your arm up away from your body. The two Teres minor and infraspinatus are located more in the back of the shoulder and allow you to rotate your arm away from your body. These four muscles act in concert so that they all work together to give you this wonderful motion over your head.
Rotator cuff tears typically affect people’s lifestyle in a negative way. People will have pain and dysfunction in their shoulder when they raise their arm overhead. Pain is usually the presenting symptom to the doctor because it’s hard to live with pain, especially when you can’t do what you want to do. In the interim, while you’re waiting to see the doctor, things that you can do to treat rotator cuff tears are use things like ice or oral anti-inflammatories such as Motrin, Advil, or Aleve, or any other over the counter or oral anti-inflammatory. Typically resting the shoulder and avoiding certain stresses that involve overhead activity typically also help.
Some of the causes of rotator cuff tears are degenerative in nature, meaning that they occur over time as a wear and tear phenomenon. This is typically seen in patients who use their arms over their head quite a bit, such as painters or laborers or even people that do cashier work or stock shelves. Typically, this is caused by one of two things: one of which as we age, the blood supply to the rotator cuff muscles in our shoulder becomes less and less. You can imagine blood brings in all the healing potential of the body. It brings in the nutrients and the proteins and all the things that our body needs to heal itself. Unfortunately, as the blood supply goes away, the ability of the body’s innate capacity to heal itself is also diminished and this can result in a tear. Other things that can cause tears are things like bone spurs in the shoulder. We know that as our shoulder, we use it for a number of years, you can develop some bone spurs that form in the shoulder blade. When this happens, every time you raise your arm above your head, that bone spur pushes down on the rotator cuff muscle and over time causes a tear. This is known as external shoulder impingement and is a known cause of rotator cuff tears. I call this the cheese grater effect where the bone spur is essentially pushing on the rotator cuff muscles, and every time you use it is grading it down slowly and slowly to where over time, this leads to a full tear of the shoulder.
In some instances, surgical repair is not able to be performed for rotator cuff tears. Sometimes if the tear has occurred long ago and the tissue quality cannot hold the stitch so that it can be repaired, patients are left with a couple of other options. Tears that can’t be repaired can be managed with something called a reverse shoulder replacement, which is a metal and plastic shoulder replacement that allows for the patient to reach up over their head and usually is very good at eliminating pain. This is a much larger operation than a rotator cuff repair, and the recovery is typically longer.
Most of the same type of repair and strength can be imparted onto the tissues to allow normal healing. One approach that has gained popularity over the past decade or so is arthroscopic repair of the rotator cuff muscles. This involves small poke holes around the shoulder where a camera is inserted into the shoulder, the tear identified, and then through various techniques, the rotator cuff muscle is repaired down to the bone. The benefit of an all arthroscopic repair is that the recovery time is typically less because the incisions are smaller and there’s less damage to the normal tissue of the shoulder.
Most patients that end up needing some surgery for their shoulder for rotator cuff tears typically have many surgical interventions performed. This involves cleaning up the shoulder joint of any loose tissue that may be pathologic in causing pain. Removing bone spurs from the undersurface of the shoulder blade called the acromion. Removing the Bursa from the shoulder, which also causes pain. Sometimes the bicep tendon inside the shoulder joint is also found to be a significant source of pain. If this occurs, in conjunction with a rotator cuff tear and repair, you may have the biceps tendon released or released and reattached down in the arm outside of the shoulder. For the biceps tendon, that means that the biceps tendon is removed from the shoulder and can’t cause a significant source of pain along with the fact that it addresses all the pain generators in the shoulder to allow patients to have a more normal shoulder at the end of the operation.
Some of the risk factors for rotator cuff tears are age. We know that as patients age, they have a higher incidence of having a rotator cuff tear. So for example, a 60-year-old is much less likely to have a tear than an 80 year old. And we know that as we age, these tears become more common. This is probably an effect just of use of the shoulder over time. Other risk factors are people that do manual labor, people that like painters or plumbers that use their hands to make a living, have greater wear and tear on their shoulder, and typically can develop these tears over time. Other professions, like professional athletes, for example, baseball pitchers that do a lot of throwing are also at risk for having rotator cuff tears develop over time. Rotator cuff tears typically develop later in life, usually after age 40. Again, and this is likely due to just wear and tear on the shoulder.
The symptoms of a rotator cuff tear are typically related to pain and weakness. Patients typically have difficulty sleeping at night because their shoulder will wake them up secondary to pain. A lot of times they’ll have difficulty sleeping on their shoulder. Typically, this is worse in patients that are side sleepers and they note that the thrash around at night to try to get comfortable. Other things that patients typically notice is that they become weak as they lift their arm over their head. Normal things like getting dishes out of the cupboard become difficult and you feel like the arm is going to give out on you. Patients will note some weakness even using their hand away from their body and in advanced cases will note that they can’t get their head even behind their head or up their back to scratch it. For men, this is manifested as difficulty getting their wallet out of their pocket. For women, it typically involves having difficulty getting a bra on as they get dressed in the morning.
Patients with rotator cuff tears are usually not candidates for a standard shoulder replacement because we know based on studies that have been done in the past, that if a rotator cuff tear is present in a normal shoulder replacement, this can lead to failure of the implant at a much quicker pace than is expected.
When a rotator cuff muscle is torn, it is typically because of one of two processes. The first is something called an acute tear, which means that there’s been some trauma to the shoulder. Whether this is involved in falling on your shoulder or you’re lifting something heavy and feel a pop, this is a tendon that was attached to the bone or muscle that was attached to the bone and has been ripped off because of some traumatic event. The other type of tear is something called a degenerative tear, and this is one that develops over time because of overuse. Typically, this is because of using your arms over your head a lot or something that is just kind of worn down over the years and eventually leads to a full tear in the shoulder.
Some of the latest research on rotator cuff tears is finding out exactly what causes the patient to be symptomatic. And when I say that, I mean if you took a hundred people off the street and put them in an MRI scanner of their shoulder, even if they didn’t have pain, some patients would have rotator cuff tears. The real research has been finding people with tears. When do they develop pain and when does the tear become big enough that it imposes dysfunction on the shoulder? Much of this research has been done at Washington University in St. Louis with ultrasound and natural history studies that are funded by an NIH grant. What we seem to be able to conclude from these studies is that rotator cuff tears typically get larger with time and the larger they get, the more likely they are to become symptomatic. We also know that rotator cuff tears don’t heal themselves. And so in younger patients and patients with high demand activities and those who can’t do what they want to do, a recommendation is made for surgical repair because of these. Some of the other research has focused on the strength of the surgeon’s repair. Whether this means using one anchor in the shoulder for repair or using two anchors or sometimes even up to four anchors. We’re trying to figure out from a biomechanical standpoint, what’s the strongest repair that the surgeon can do to give patients the best chance to heal their tear? Some of this research is inconclusive, but different techniques such as single row repair or double row repair have been studied and we know that double row repairs are stronger. Unfortunately, no one has yet been able to show that this translates into clinical improvement. What I mean by that is that patients that have a single row rotator cuff repair and patients that have a double row rotator cuff repair seem to do the same in the end right now. This may change in the future as further research is taken under and the exact retear elucidated.
Patients with rotator cuff tears oftentimes needs some form of physical therapy in order to progress with both their motion and pain. Patients that elect to treat the tears of their shoulder, nonoperatively and without any kind of surgery, typically need to restore their motion by recruiting other muscles in their shoulder so that they can use their arm normally overhead. Generally, they set up an appointment with a physical therapist and have a minimum of about 12 sessions in order to really function on restoring the motion in your shoulder and using some of the other muscles in your shoulder to provide some of the strength. Some patients with mild symptoms can be given a home exercise program. This involves a series of exercises that focus on strengthening the muscles around the shoulder and even the muscles that are torn to help regain and restore some of the motion and some of the strength. It is up to your doctor to determine whether you need a formal physical therapy evaluation or if this is something that you can do as a supervised home exercise program.
Surgery for rotator cuff tears is warranted when a patient has failed conservative measures or has a tear that is so large that it is causing significant dysfunction of the shoulder. Insurance companies typically like to see patients that have gone through a conservative treatment and not gotten better. When I say that, I mean things like trying anti-inflammatory medications, home exercise programs, and even steroid injections such as cortisone in the shoulder should be considered first. Once a patient has had each of these and failed to improve to a lifestyle or a point that they’re satisfied with, a lot of times those need to be undertaken first before surgical intervention is considered. Insurance companies will almost always pay for this kind of surgery once those criteria have been met.
Some professional organizations that are involved and interested in rotator cuff tears are things like the American Academy of Orthopedic Surgeons. This is known as the AAOS and much information can be found on their website, such as www.orthoinfo.org and this can provide information on the natural history of rotator cuff tears, the surgical interventions that are used, and even provide sometimes videos that can demonstrate the surgeries.
Some of the nonsurgical treatments for rotator cuff tears are things like resting the shoulder, avoiding vigorous activities that are known to aggravate the shoulder. These are typically over the head activities. Some of the other things such as oral anti-inflammatories will help decrease the pain and inflammation in the shoulder. Typically, these work in a scheduled fashion. When I say that, I mean, patients that take Ibuprofen typically have to take it four times a day in order to really maximize the effect. Other anti-inflammatory medications like the Naproxen can be taken twice a day and have the same effect. One of the most effective treatments is to have a corticosteroid injection such as cortisone into the shoulder to allow for maximum relief. Cortisone is one of the most potent anti-inflammatory medications we have available and it usually works in about 24 hours and gets rid of the inflammation around the area. Unfortunately, none of these things help the rotator cuff muscle heal. Tears that are in the rotator cuff muscle will in general not heal back to where they came from with conservative treatment such as those mentioned.
An MRI is typically done at an outpatient basis and typically takes about 45 minutes. Some doctors will order an MRI arthrogram. An arthrogram involves and injection of dye into the shoulder joint just prior to having an MRI. Although it’s a little more invasive, it typically does give a little more information. An ultrasound is a new imaging technique that is being used more and more commonly in the office to aid in the diagnosis of rotator cuff tears. An ultrasound is a portable machine where a probe can be put on the shoulder and utilize essentially no radiation at all. The ultrasound uses sound waves to image the rotator cuff muscle and will allow for the diagnosis of tear as well. The benefits of an ultrasound is that it can be performed usually onsite in the doctor’s office and allow for an immediate diagnosis. Unfortunately, you typically don’t get as much information from an ultrasound as an MRI.
So when people say that they have a rotator cuff tear, what that means is that the muscle and the tendon that normally attached to a bone like your shoulder bone are torn away. When that happens, when the muscle contracts, it can’t adequately move the arm any longer, and so there’s some impairment of function in the shoulder. These tears typically do not heal themselves because the muscle, in order to function effectively, is under some tension at baseline, and that’s the same for every muscle in our body. Unfortunately, when these muscles are under tension and they tear, they don’t just tear away from the bone. They tear and retract almost like a rubber band when it snaps. This then puts the tendon away from the bone so that when the muscle contracts, it can’t move the shoulder bone normally.
A diagnosis of a rotator cuff tear is confirmed usually with an MRI or an ultrasound. This allows imaging of the tendon and can give the doctor an idea of if the tear is a full tear or a partial tear, which will then allow for treatment options to be discussed with the patient.
Some of the associated conditions that go along with rotator cuff tears are different things like diabetes or thyroid problems. We know that these conditions typically impair the blood supply to certain areas and for rotator cuff muscles, and its no different. Patients with diabetes do have a higher risk of developing a rotator cuff tear and a higher risk of even healing the tear once it is torn.
Typically, a rotator cuff tear presents with weakness and pain. Oftentimes patients present with what we call nocturnal pain – nocturnal meaning nighttime pain – so if you’re having pain at night in your shoulder and you’re having trouble sleeping, if you’re having trouble lifting your arm over your head, and if you’re over the age of 40-50, then those would be signs and symptoms that are consistent with some sort of a rotator cuff tear, whether it be a partial tear or perhaps a full thickness tear.
When you see your orthopedic doctor, your doctor will assess the mobility of your shoulder, will assess the strength. We have ways of assessing the integrity of the rotator cuff with certain physical examination findings in order to see if your rotator cuff is still intact. We also inspect the shoulder, look to see if there’s any evidence of atrophy in your shoulder – meaning the muscles are weakened for one reason or another. Oftentimes, we’ll get x-rays of your shoulder to assess for other conditions like arthritis of the shoulder. With the physical exam and the diagnostic imaging (namely in the office – most commonly it will be x-rays), your orthopedic doctor should have a good sense of whether you have a rotator cuff tear. If there is concern for a rotator cuff tear, oftentimes your doctor will order an MRI. An MRI is a great test because it allows us to see the soft tissues in the shoulder. It will show us your ligaments. It will show us your cartilage. It will show us all of the rotator cuff. It will allow us to see if you have a rotator cuff tear, whether it be a partial thickness tear or a full thickness tear.
If you’re having shoulder pain and you’re concerned that you may have a rotator cuff tear, things to consider would be: do you have weakness? If you have weakness in your shoulder, then you may have a rotator cuff tear. For instance, if you can’t bring your arm up over your head, that is an indication that you may very well have some sort of an issue with your rotator cuff and I would suggest seeing an orthopedic surgeon if that is the case. If you’re just having some pain in your shoulder and you’re not sure what’s going on, then I would suggest starting with a course of a heat application, anti-inflammatories, rest. Oftentimes I’ll see patients who have shoulder pain and it was just that they had played five hours of beach volleyball over the weekend and their shoulder is hurting. So if the case is where you’re having shoulder pain and it just came on over the weekend after playing flag football, then I’d say probably just give it a rest and see if he gets better with anti-inflammatories, maybe some heat and rest. If it doesn’t and you’re still having difficulty moving your shoulder, then I would suggest seeing an orthopedic doctor for further evaluation.
If you’re having pain in your shoulder and you’re concerned that you may have a rotator cuff tear, things to consider would be: “Did I hurt my shoulder? Was there something specific that happened?” Also: “Can I bring my arm up over my shoulder? Am I weak?” Depending on your symptoms, the symptoms very much help dictate what’s going on and it might save you a trip to the doctor. If you can bring your arm up over your head, don’t have much weakness or any weakness, and you’re 35 years old, it’s very unlikely that you have a rotator cuff tear. In general, rotator cuff tears are very uncommon in patients 40, 45, and younger. So if you’re below the age of 45 or so, it’s unlikely to be a rotator cuff tear. Very frequently I’ll have patients come in who are 20-30 and they’re convinced that they have a rotator cuff tear and almost without fail, they do not have a rotator cuff tear. They have a shoulder issue, but it’s not a rotator cuff tear. Now, if you’re in your 50s or above and you’re having pain or weakness in your shoulder, you’re having difficulty sleeping at night and perhaps you lifted up a heavy pail when you’re working in the garden over the weekend, then yes – that certainly would be something concerning for a rotator cuff tear. I would suggest seeing your orthopedic surgeon for an evaluation.
When patients present with shoulder pain, it can be numerous things and that’s why it’s helpful to go and see an orthopedic doctor. Your doctor can assess for the various shoulder problems that you may have. The other things that it could be that would be that at the top of your doctor’s differential diagnosis list would be: a labral tear. The labrum is a structure that goes around the socket. It’s like a bumper that goes around your glenoid and that provides structural support for the humeral head. That’s something to consider and that also can present with pain and weakness and difficulty lifting your arm up over your head, so that’s something else to consider would be a labral tear. With a rotator cuff tear – you can also have issues with your biceps tendon. The long head of your biceps (the biceps are what allows us to not only flex our elbow, but also (more importantly) allows us to do what’s called supinate, which is this motion *demonstrates*. One of the two heads of the biceps tendon actually originates in the shoulder joint and it runs down the humeral head down into the arm. That tendon oftentimes can get degenerated and it can be associated with a rotator cuff tear. So that’s something else to consider and that’s another possible cause of pain. Arthritis is another very common finding. Oftentimes, patients have all of the above. A 65 year old man who has been active, enjoys playing golf, for instance, can come in with shoulder pain, weakness, limited mobility. I’ll get x-rays which will look okay, and then I’ll get an MRI, will show a full thickness rotator cuff tear, degeneration of the long head of the biceps, a labral tear, and sometimes some arthritis as well.
Rotator cuff tears can be traumatic. It can be from a motor vehicle accident, or falling out of the tree. It can be seen in high level athletes, but it’s unusual because patients in their 20s and 30s and teens have such strong rotator cuffs that it’s unusual to have a tear in that age group, but it is possible. In the weekend warrior population, it’d be more likely. Weekend warriors being say, late 30s, early 40s, 50s – men in particular who are playing softball or flag football and they injure their shoulder. The problem is that as we get older (say 45 and above), the rotator cuff is less well perfused with blood. Our cuff just doesn’t get as much blood supply as we get older. Because of that, it’s more prone to degeneration and more prone to tearing. That’s why we see rotator cuff tears more commonly in the elderly population than in middle aged people and in youth.
Risk factors for rotator cuff tear: the number one would be age. A second would be some sort of trauma. Whether you’re young or old, if you have some sort of shoulder trauma, it is entirely possible that you could have an injury to your rotator cuff. There also are anatomical issues that can put patients at an increased risk for a rotator cuff tear. For instance, there’s a bony structure in the shoulder that’s called the acromion. The acromion comes off of our scapula and it overlies our rotator cuff. The acromion can have three different configurations: There’s a type 1 acromion, which is flat like this *Demonstrates*. Then there is a type 2 acromion which has a gentle curve, which is the most common type of acromion that I see. Then there’s a type 3 acromion which is like a hook at the end of the acromion. When patients have that anatomy with the hook, that puts them at increased risk for rotator cuff issues because that acromion can irritate the rotator cuff and cause rotator cuff tears.
Unfortunately, a rotator cuff tear will not heal on its own. If a patient has a full thickness rotator cuff tear, if they’re active, generally the treatment for that would be to fix it because it will not heal itself. If you don’t fix it, then the problem is that not only can a patient have persistent pain and weakness, quite frankly, very limited function of their arm or of their shoulder, but they can ultimately develop what’s called rotator cuff arthropathy. What rotator cuff arthropathy is: the humeral head is maintained within the socket (which is the Glenoid) by a series of ligaments and also by the rotator cuff. So if all or (more commonly) a portion of your rotator cuff is torn off of the bone, it scars down. Sometimes it gets to the point where it cannot be brought back over and then it gets to be too late, so you can’t repair it anymore. The problem with that is if your rotator cuff tendon is retracted and scarred down, it’s not acting as a stabilizer of the shoulder. So then what happens is the humeral head starts to migrate up, starts to shift up out of the joint, and that alters the biomechanics of the shoulder joint. Because of that, patients develop arthritis because the biomechanics (the way the shoulder joint works) is out of whack and it causes degeneration of the cartilage, which leads to even more pain because then patients have a rotator cuff tear that’s not repairable and bad arthritis in their shoulder. That’s a very difficult problem.
In general, if a patient has a rotator cuff tear, I don’t immobilize them with any sort of a sling or brace. Generally, the treatment for a rotator cuff tear that’s going to be treated conservatively would be activity modification – namely: usually avoiding overhead activities that are stressful to the rotator cuff – and some physical therapy to strengthen the shoulder. Sometimes I’ll give a patient a sling if they’re having a lot of shoulder pain and they’re needing something to protect the shoulder and when they’re out and about in public, they don’t want to have somebody coming up to them and saying, “hey Joe, how you doing?” and hitting them on their shoulder. So sometimes we’ll do that, but for the most part, I think it’s important to actually keep the shoulder moving because if you just put it in a sling for a period of time, it will get stiff. And then you’ll have two problems: you’ll have a rotator cuff tear with a stiff shoulder.
The indications for surgery depend much on the degree of the tear. If it’s a full thickness tear in someone who’s very active and if it’s their dominant shoulder, then I would tend to suggest surgery for that. If it’s a 65 year old man who plays tennis on the weekends and he can’t get his arm up over his head and he has a full thickness rotator cuff tear, it’s very unlikely that a course of physical therapy is going to address his problem. For a patient like that, I would generally suggest repairing the rotator cuff because that will allow him to get his arm up over his head and do basic activities of daily living and hopefully allow them to get back to activities that he enjoys. For partial thickness tears, generally I will suggest starting with conservative management – with a physical therapy, perhaps a cortisone injection, and activity modification to avoid excessive overhead activities to prevent aggravating the condition.
In this day and age, most orthopedic doctors repair the rotator cuff arthroscopically – meaning it’s minimally invasive. We use a camera to assess your rotator cuff arthroscopically through small incisions about your shoulder – we look at your shoulder on a TV screen. Through small incisions at about your shoulder, we’re able to mobilize the cuff tear because sometimes it can get scarred down with time. So we mobilize the torn rotator cuff, free it up from scar tissue. Then what we we do is we put a suture in it and the suture is like rope that we put into the cuff. Then we use that suture to pull the rotator cuff back into its anatomic position onto what’s called the greater tuberosity. If it’s a superspinatus or infraspinatus tear, the supraspinatus and infraspinatus are the two muscles that insert onto the greater tuberosity. So for instance, the superspinatus, which is most commonly torn rotator cuff tendon, we put suture into it and then there are different methods of fixation, but most commonly an anchor (which is a little anchor that goes into your bone and stays there and usually it’s reabsorbable and reabsorbed into the body with time) – the screw or the anchor goes into the bone and then the tendon gets reattached back down to the greater tuberosity with a suture that goes into the bone with its anchor. That holds in place while it heals over the course of about 3 months.
In general, the recovery from a rotator cuff surgery is about 3 months. In general, I see patients a week after surgery. I check their wounds, show them the pictures from surgery, show them what I did, and then get them going with physical therapy right away. I think it’s very important to get the shoulder mobilized. Now there are certain restrictions with your activities. For instance, if you have the supraspinatus tendon repaired, which is the most commonly torn rotator cuff tendon, there are restrictions and you can’t bring your arm up over your head actively for about 6 weeks. The therapist works with you on getting your shoulder moving to prevent stiffness. At around the 6-week point, for my patients, I allow them to start moving their shoulder freely without restrictions. Generally at the 3 month point, patients are able to bring their arms up over their head and they’re able to sleep again at night without pain, their strength has improved, and their pain is (for the most part) resolved.
The patient’s work situation is dependent very much on what they do for living. A lot of my patients work at a desk and in those cases, more often than not patients will return to work within a couple of weeks. Laborers – when I see workers comp patients, for instance, a lot of my workers comp patients are heavy duty laborers. They will be out of work at least 3 months because you can’t do heavy duty activities with the affected shoulder for at least 3 months after surgery.
The treatment algorithm for a rotator cuff tear depends a lot on the patient: the patient’s age, their activity level, and the degree of the tear. If it’s a partial thickness tear, generally my protocol for that would be to start with a course of rehabilitation – physical therapy, activity modification, anti inflammatories (Ibuprofen, for instance). Perhaps a cortisone injection – a cortisone is an anti-inflammatory – I can inject cortisone into the region where the rotator cuff tear is. That can help settle down the inflammation in the region – it will not heal the tendon. The cortisone is an anti-inflammatory – it will help with the inflammation but it doesn’t heal anything. One common misconception about Corazon actually, (which I hear not infrequently from patients) is that it’s bad for the body. It is true that cortisone (if given too often) can be deleterious to your tissues. But cortisone given appropriately by a medical professional and given not too frequently can be a very helpful adjunct to treating various issues such as rotator cuff tear because it can help settle down the inflammation and help markedly with your pain for some period of time. So a cortisone injection, physical therapy, anti-inflammatories would be the first line of treatment for a partial thickness tear. For a full thickness rotator cuff tear, a lot of it depends on the patient’s age and activity level. If it’s someone who is elderly and not particularly active, if it’s their non dominant arm, then I’d be more likely to try a course of physical therapy and maybe a cortisone injection. If it’s someone who’s 70 but loves playing golf or tennis, and it’s really affecting their quality of life, then I would suggest fixing that surgically because by repairing it, it will allow them to hopefully get back to performing the activities that they enjoy.
The activity modifications that I would suggest for a partial thickness rotator cuff tear or a full thickness rotator cuff tear would be avoiding excessive overhead activities at the gym. Golf would be difficult. Tennis will be difficult. Really anything overhead is going to be difficult. It will be difficult to do anyway. As you may know, when you’re trying to do these activities, if you have a partial or full thickness rotator cuff tear, sometimes you can’t get your hand up over your head anyway, so avoiding overhead activities – putting a luggage in the overhead bin on an airplane – that would be bad, that can aggravate the condition. Things of that nature should be avoided. Then, if you go to see a physical therapist, they’re going to work with you on strengthening the muscles around your rotator cuff. They’re going to be working on strengthening the scapular stabilizers of your shoulder and the scapula (the wing bone) – the bone in the back of your shoulder. By strengthening the muscles around your rotator cuff, that can help with your pain and your mobility.
There’s no guarantee that you can prevent yourself from developing a rotator cuff tear. Even if you’re very cautious about the activities that you perform, it is entirely possible that you could develop a rotator cuff tear. In fact, not infrequently I see patients in their 60s or 70s who have had no trauma and they just have pain in their shoulder and they have a rotator cuff tear. So unfortunately there’s no magic way of preventing a rotator cuff tear from developing. Certainly, there are activities that we can avoid that can help prevent rotator cuff tears and particularly as we get older, these are activities that one should consider avoiding. Any sort of high impact overhead activities, for instance, can be impactful to the rotator cuff. Something as simple as putting a suitcase in the overhead compartment – something that you might have done without thinking when you were in your 20s and 30s, when you get to be in your 50s and 60s, if you try and lift that 50 pound bag up and put it into the overhead compartment, you might find that it really affects your shoulder. So somebody to consider. Also getting it out – just as simple as pulling it out – I’ve seen many times patients in their 50s and 60s pulling their suitcase out of the overhead compartment and they tear their rotator cuff. So things that you take for granted when you’re younger, as we get older – unfortunately those things can be harmful to the rotator cuff and those are things to think about.
One area of interest for a sports medicine doctors right now is PRP – Platelet Rich Plasma or stem cells. They are different – stem cells are undifferentiated and stem cells can become just about anything in your body. PRP is not. PRP is Platelet Rich Plasma, which are the platelets in your body that have been shown to help with healing in certain tissues. There’s interest in using PRP in the rotator cuff, but the data to date shows no significant improvement with using PRP or stem cells, for instance, when repairing the rotator cuff. It’s something that’s interesting and perhaps in the future will be something that we use commonly for rotator cuff repairs or for conservative management of partial thickness rotator cuff tears. It certainly would not be unreasonable to try PRP, for instance, for a partial thickness rotator cuff tear but one of the problems with PRP and stem cells is cost. PRP might cost $1,000 for an injection. Stem cells can cost anywhere from $5,000 to $7,500 or perhaps even more for a one-time injection. They are cost prohibitive and there’s no great data right now to support the use of PRP or stem cells for rotator cuff tears.
Unfortunately, as we age, these muscles can have some wear and tear on them like other parts of your body. These muscles act to keep the shoulder joint centered and give you pain free motion. Unfortunately, they can be pathologic. The bursa sac sits between the shoulder blade and the rotator cuff muscles. As you raise your arm, that sac serves as a cushion to keep the rotator cuff muscles from rubbing under the under surface of your shoulder blade. This normally works great and allows you to reach over your head and do normal things away from your body without any pain. Unfortunately, if the rotator cuff muscles become inflamed, this also causes inflammation of the Bursa known as bursitis. The bursitis can be just as painful as a tear in your shoulder and can cause you difficulty with many things such as using your arm normally and even sleeping at night.
Various imaging modalities are used in the office and out of the office. In order to confirm the diagnosis of rotator cuff tear. X-Rays are typically done as a baseline in order to assess the health of the joint and to ensure how much arthritis, if any, is involved. It also allows to study the basic anatomy of the shoulder and does give the musculoskeletal physician some hints about how long some of this stuff has been going on and the overall health of the shoulder joint. In order to confirm the diagnosis of a rotator cuff tear, things like MRI or ultrasound are used to image the soft tissue structures of the shoulder. Whereas an x-ray will not show the rotator cuff tendons an MRI or an ultrasound can be used to look for this. This will not only allow for the diagnosis of a tear, but will also allow for the diagnosis of how long this tear has been going on for and how healthy is the tissue. This is important because it aids in the decision making for surgery. A lot of times, general conclusions can be drawn based on the health of the muscle on an MRI or ultrasound to determine whether a tear can or cannot be even fixed.
When preparing for your appointment to evaluate for a rotator cuff tear, it’s really important to pay attention to your symptoms. You want to know is it just pain that’s bothering your shoulder? Or is it pain and weakness? Are you having problems reaching up over your head? Are you having problems sleeping at night? Is the pain keeping you awake? These are all things that you want to pay attention to. Some of the things that you should also notice what makes it better? Does resting it make it better? Does taking anti-inflammatory medications like Ibuprofen, make it better? These are all important things for the doctor to keep in mind when evaluating you. One of the things you want to note also is how long has it been going on for? Did this develop as a result of trauma? Or is it something that has been nagging you for a number of years? All this information is useful in formulating a treatment plan for the patient and it’s usually useful if you think about these things before.
A rotator cuff tear oftentimes presents with pain and weakness in the shoulder. A patient will present – it depends oftentimes on the age. Rotator cuff tears are very uncommon in youth and in patients 20-40, maybe even 50. Rotator cuff tears are much more common in the 50+ age group. Generally if a patient (20, for instance) comes into my office with shoulder pain and weakness, it’s pretty unlikely that it’s going to be a rotator cuff tear unless they fell out of a tree or were in a high speed motor vehicle accident or something of that nature. Now, if a 65 year old comes into my office and says, “you know, doc, I was putting something in the overhead bin on the airplane and all of a sudden I had a sharp pain in my shoulder. I haven’t been able to lift my shoulder over my head since then. What’s going on?” – that’s more likely to be a rotator cuff tear. Because the rotator cuff allows us to do exactly that – bring our arm up over our head. So oftentimes it will present with weakness and pain. If you’re having pain in your shoulder and you’re having difficulty lifting your shoulder up over your head, if you’re having difficulty sleeping at night, then I would suggest seeing an orthopedic surgeon for evaluation of your shoulder pain.
You were born with some type of acromion, whether it be a type 1 (which is flat), a type 2 (which is curved), or type 3 (which has more of a hook at the end) and it’s going to be the same on both sides. That’s just the way you’re born. You cannot know what type of acromion you have without getting x-rays of the shoulder. There’s a certain view we look at called the Scapular Y View, which is when we see the scapula and it looks like a “Y” because we’re looking at it from the side. That allows us to see the acromion from the side and that is when we can determine what type of acromion a patient has.
Rotator cuff tears can be divided into: partial thickness rotator cuff tears, which are very common. Oftentimes patients present with the exact same findings: weakness and pain. In order to diagnose that, you need to get an MRI in terms of delineating between a full thickness and a partial thickness tear. That’d be very hard to determine that based on a physical exam or x-rays. An MRI would allow you to determine whether a rotator cuff tear is a partial thickness tear or a full thickness tear. A strain of the rotator cuff would be not uncommon in athletes, for instance: overhead athletes who are throwing – football players, baseball players. A strain would be some inflammation of the tendon or the muscle itself, but the actual tendon is not pulled off the bone. In a rotator cuff tear, the actual tendon has pulled off the bone, which is called the greater tuberosity. It’s a bony prominence on the humeral head where the rotator cuff inserts and when the tendon tears, it pulls off that bone.
The rotator cuff is a series of four muscles in the shoulder: the Supraspinatus, Infraspinatus, Subscapularis, and Teres Minor. It’s four muscles in the shoulder region that insert onto your humeral head. They’re very important muscles because not only do they allow us to move our shoulder, but they’re actually also dynamic stabilizers of the shoulder. What that means is that these are actual muscles that help keep the shoulder within the socket to allow for stability of our shoulder because our shoulders a very special joint because it has so much mobility. If you think about your shoulder, you can move it quite extensively in comparison to say, your knee, which essentially goes like this *demonstrates* or your hip, which doesn’t have much motion either, relative to the shoulder. What allows us to have that is if you think about the anatomy of the shoulder, it’s essentially a dish which (we call the glenoid) – that’s the socket and then you have your humeral head. There’s not a whole lot of stability between a ball and a dish, so we need stabilizers of the socket. We have static stabilizers, which would be the ligaments, and then we have dynamic stabilizers, which are the muscles. The rotator cuff are four muscles within our shoulder that provide both stability for the shoulder and allow us to move our shoulder.
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