Rotator Cuff Tendon Tears of the Shoulder
The shoulder in a "ball and socket" joint which explains its remarkable mobility. The roof of the shoulder is called the acromion. The acromion is the firm bone that you can feel on the top of the shoulder, just past the collar bone. Attached to the acromion is the deltoid, a large muscle covering the outer part of the shoulder or upper arm. The proximal humerus, or ball, is held in place by a series of muscles and their tendons, which are called the rotator cuff. The rotator cuff lies deep to the deltoid and acromion. When one raises their arm the rotator cuff may rub on the underside of the acromion, or roof of the shoulder. This pinching or rubbing of the rotator cuff is referred to as impingement of the shoulder. Over many years impingement may gradually result in wearing and eventual tearing of the rotator cuff.
Additionally, the blood supply to the rotator cuff is rather limited and it therefore does not have much potential for healing or self-repair. Impingement with its gradual wearing of the rotator cuff and the limited blood supply combine to make tears of the rotator cuff a natural part of the aging process. Generally, the rotator cuff is very strong in younger individuals and therefore it is uncommon for a tear to develop in an individual younger than the age of 50 without significant trauma. As one's age increases tears of the rotator cuff occur more easily and often without trauma. By the time an individual reaches the age of 70 there is a 30% chance that that person has a tear of the rotator cuff.
The main symptoms include:
- Pain at the front of the shoulder when reaching forward or overhead
- Pain on the outer side of the shoulder which can extend or radiate below the shoulder and occasionally into the elbow or forearm
- Popping, catching or grinding
- Weakness and/or loss of motion.
In the older population we find that patients can often tolerate a loss of strength and motion quite well. Although not all patients complain of significant pain, this is the most important symptom. The main indication for surgery is significant pain - pain that seriously interferes with the activities of normal daily living and, more importantly, night pain. These patients often lay awake secondary to pain and end up pacing the floor at night and/or sleeping in chairs.
The most important part of your evaluation is a thorough history and physical examination. Your doctor will interview you and then examine your shoulder for pain or tenderness, weakness, muscle loss and restricted motion – often attempting to reproduce the popping, pain and other symptoms. X-rays are also obtained to look for bone spurs, arthritis, calcification of the tendons and rarely bone cysts or tumors.
Additional sources of pain are also evaluated. In cases suggestive of a 'pinched nerve' a thorough neck exam is performed as well as cervical spine X-rays and additional tests may be requested to rule out shoulder pain that is not from the rotator cuff, but referred pain from the neck.
In addition to regular X-rays another type of X-ray may be performed at the hospital or an outpatient radiology center– called an arthrogram. For this test the radiologist uses a needle to inject a fluid into the shoulder. This fluid shows up on an X-ray and will confirm the diagnosis of a rotator cuff tear if the fluid leaks out of the shoulder joint through a tear in the rotator cuff. This test is quite good and picks up 90 to 95% of the tears of the rotator cuff.
More recently the standard arthrogram has been replaced by MRI scans or in some cases a MRI plus arthrogram. For a MRI the patient is required to lie still in a large tube for about 20 to 30 minutes as the machine 'takes pictures' of the shoulder. While X-rays show the bones, MRI scans show soft tissue structures such as tendons and ligaments. This test is also very good for picking up tears, but may miss smaller and partial thickness tears 5 to 10% or the time.
After the initial evaluation a treatment plan is formulated. The proposed treatment is individualized with treatment being tailored to each individual based on age, severity of symptoms as well as what the patient wishes to gain from treatment. When treating a younger person or a physical laborer we may consider surgery sooner, while in an older patient surgery will generally be reserved for those patients who have significant pain that is unacceptable to the patient and which has failed to respond to an initial more conservative treatment. Non-surgical treatments, in addition to activity modifications include:
Anti-inflammatory medications: Aspirin-like medicines that decrease pain and inflammation (i.e. Advil, Motrin, Aleve, Vioxx, Celebrex, Bextra and others).
Physical Therapy: Therapy is often prescribed to assist the individual in strengthening those muscles that still remain. The therapist may also use ultrasound and other treatments to reduce pain and inflammation.
Injections: Occasionally an injection of cortisone may be offered or recommended in an attempt to calm the shoulder down to a more tolerable level.
Surgery: Once again not all patients are treated the same. Surgery may be offered to an athlete who continues to have a painful shoulder that has failed to respond to a period of rest, therapy and medications, and only if the patient feels that giving up athletics is an unacceptable option.
Surgery is recommended in the physical laborer who has a confirmed tear of the rotator cuff and significant disability. The surgery is performed in hopes that the individual can be returned to work - although some permanent limitations may be expected even with surgery.
Surgery may be recommended, or at least offered, to an older individual who has significant shoulder pain that has failed to respond to all other treatments. Surgery in this group is generally 85% successful in relieving patients of their night pain; however, the surgery may not be successful in restoring strength, motion or function.
Generally the rotator cuff pulls away from its attachment onto the bone when it tears. It is therefore sewn back to the bone using sutures that pass through the bone and are tied below the level of the tear. Depending on physician preference an arthroscopy may be performed. At the time of the surgery a small instrument (an arthroscope) is inserted into the shoulder to assess not only the rotator cuff but also the rest of the ball and socket joint. In individuals who have tendonitis or impingement the inflamed tissue is removed and the acromion (roof) is shaved to allow more room for the rotator cuff to prevent further wearing or impingement of the cuff. Although small tears of the rotator cuff may occasionally be repaired arthroscopically most tears, however, are then repaired through a small incision. In those individuals who require an open repair of the cuff, a small incision is then made at the tip of the shoulder, opening the deltoid muscle and exposing the tear of the rotator cuff, which is then repaired.
To prevent stiffness we will start you on some very limited physical therapy or exercises immediately after surgery. These are gentle exercises where you lean forward and then gently swing your arm like a pendulum, (like an elephant swinging its
Sleeping may be very difficult for the next number of weeks. You should take pain pills as needed. Many patients often find it easier to sleep upright or semi-upright in a 'lazy boy' type of chair.
Most patients are immobilized after surgery in a special sling that has a pillow that fits under the arm, holding it out to the side. This may be worn from 4 to 8 weeks after surgery. No elevation or raising of the shoulder should be attempted during this time, (except by the therapist). It will be 8 weeks from surgery, in general, before we allow you to lift the arm out to the side, with the elbow bent. At 10 weeks we will allow you to raise or lift the arm out to the side with the elbow straight. It is important to understand that after the surgery the repair must be protected. The tendon which has been secured to the bone by the small sutures, or thread, gradually heals to the bone over a number of months and therefore caution must be exercised to obtain the best possible result. It actually takes six months before the attachment of the rotator cuff begins to approach its normal attachment strength. Laborers often take 8 months before returning to heavy labor and a full recovery often takes approximately one year.
Generally once everything has healed and your improvement has plateaued, many patients may still remain limited from repetitive overhead activities – especially heavy or repetitive lifting above chest height. Regular lifting from the floor to waist level is often limited to 40 or 60 lbs. Although many patients fully recover the major goal of surgery is pain relief and not all patients regain normal or full pain-free motion.