Rotator Cuff Injuries
The rotator cuff is a group of four muscles that surround the shoulder joint. It is composed of one muscle in the front of the shoulder (subscapularis), one muscle on the top of the shoulder (supraspinatus) and two in the back of the shoulder (infraspinatus and teres minor). All four of these muscles originate on the shoulder blade (scapula) and form a cuff (like a shirt sleeve) and insert on the top of the humerus (arm bone). They surround the ball (humeral head) and socket (glenoid) and aid in movement of the arm in space. The muscle on top (supraspinatus) helps to raise the arm, the two in the back (infraspinatus and teres minor) help to rotate the arm out and the one in front (subscapularis) helps to rotate the arm in towards the body. Since they rotate the arm in space and form a cuff around the ball, this complex of muscles is therefore called the rotator cuff.
Rotator cuff injuries are very common and can be both traumatic and/or degenerative. The incidence of these injuries increases with age. Tendonitis is an inflammation of the tendons. Bursitis is an inflammation of a fluid filled sac between the rotator cuff and the shoulder blade (scapula). Both can typically be treated with anti‐inflammatory medications and sometimes injections with a therapeutic exercise program. Occasionally, these treatments do not provide adequate sustained relief and a simple arthroscopic procedure must be done. Advanced damage to the tendons can lead to both partial and full thickness tears of the tendons. Chronic tears can be due to both impingement from bone spurs and intrinsic damage (degeneration/tendonitis). Often, this condition can be treated with anti‐inflammatory medication, therapy and possible injections of corticosteroid. Sometimes, however, this condition also requires arthroscopic surgery. This is determined by the patient’s needs, the degree of degeneration in the soft tissues and the amount of disability and pain that the patient is experiencing. If not repaired, rotator cuff tears can get larger and sometimes lead to a type of arthritis many years later.
Injuries to the rotator cuff commonly cause pain that radiates down the side of the arm towards the elbow. It can also cause pain over the back of the shoulder blade. The pain is usually worse with specific movements such as moving the arm out to the side (abduction) and rotation. Often there is also inflammation or damage to the biceps tendon at the same time and symptoms of this may also be present. When there is a rotator cuff tear, weakness will also usually be present, particularly when the arm is out and away from the body, such as when trying to grab a gallon of milk out of the back of the fridge. In addition, pain is often worse at night. This is likely secondary to compression of the inflamed and damaged tissue against the scapula. When upright (sitting/standing), gravity pulls the arm down and away from the shoulder blade. When lying down, gravity is eliminated and the ball of the shoulder tends to drift up, squeezing the damaged tissue against the shoulder blade and, therefore, increasing the pain.
Treatment of rotator cuff injuries depends on the degree of damage as well as the needs of the patient. Non-surgical measures are often the mainstay in management. This typically involves anti-inflammatory medications and therapeutic exercises. What is important to understand with non-operative management, however, is that a torn rotator cuff does NOT heal without surgery. When these measures are no longer helpful, surgical intervention is indicated.
Surgery for the bursitis of the shoulder often involves a simple arthroscopic “clean up” procedure termed a debridement. This may include a reshaping of the acromion (shoulder blade) overlying the rotator cuff to eliminate any mechanical impingement (rubbing) of the rotator cuff and biceps. This is termed an acromioplasty and involves removal of “bone spurs” from the shoulder blade (acromion). When a rotator cuff tear is presents this is usually repaired with arthroscopic techniques. Dr. Lenarz uses a “Double Row” technique to restore the torn tendon to the original “footprint” of the tendon insertion. This is typically performed as an outpatient surgery. The most difficult part of a rotator cuff repair for the patient is the period of recovery. The initial 3 months post-operatively is focused on range of motion only and Dr. Lenarz advises his patient’s to avoid all lifting pushing and pulling with the operative arm. Failure to follow these recommendations increases the risk of the tendon being pulled away from the footprint so it is unable to heal back to the bone. After this initial 3 month period the shoulder is gradually strengthened. It therefore may take 4 to 6 months for a person to return to their normal daily activities. In the situation of a massive rotator cuff tear or revisions rotator cuff repair this time period may be extended even longer.
Occasionally, the rotator cuff tendons are not repairable with arthroscopic or open techniques or a rotator cuff repair fails and the tissue is not salvageable. In this situation, a separate open procedure may be necessary.This procedure includes the transfer of a tendon from a separate site in the shoulder to the location of the torn tendons. Dr. Lenarz uses this tendon transfer, but it is often a last step as a salvage procedure in the appropriately selected patient. This procedure requires advanced knowledge of the technique to optimize the outcome.
At times no soft tissue procedure will adequately address the damage to the shoulder. This is especially true when there is a rotator cuff tear with arthritis present. When this occurs, it is often necessary to perform a shoulder replacement called a reverse shoulder arthroplasty. More information regarding this procedure is available on the following link Reverse Shoulder Arthroplasty