Rotator Cuff Tear
INTRODUCTION
The rotator cuff is a series of 4 muscles in the shoulder that form a cuff of tissue around the humerus bone in the shoulder joint. These muscles provide rotational strength to the shoulder. Tears in the tendons of these muscles are called rotator cuff tears. The most commonly affected muscle is the supraspinatus.
There are two causes of rotator cuff tears:
Extrinsic compression
A combination of susceptible anatomy and a lifetime of wear and tear can cause mechanical abrasion and impingement of the supraspinatus on the acromion bone.
Intrinsic degeneration
Aging of the rotator cuff tendon. As we age, the quality of our tendons and the blood supply to the tendons diminishes, making the tendons susceptible to tearing.
SYMPTOMS
The symptoms of rotator cuff tears are as follows:
- Pain: Rotator cuff tears cause an aching pain in both the front of the shoulder and also the outer side of the upper arm. The pain is often dull at rest, exacerbated by overhead activity, and severe at inght
- Weakness: Due to detachment of the muscle from bone, the shoulder will be weak, especially while lifting and with overhead activity.
- Lack of Mobility: Some movements may pinch the tendon in such a way that the shoulder will not be able to rotate sufficiently to allow the arm to complete the action. Other motions may simply be too painful.
EVALUATION
- Physical exam: Is very sensitive at picking up weakness associated with rotator cuff tears. X-ray: Obtained to screen for arthritis and bone spurs
- MRI: Gold standard for characterizing size, location, and reparability of rotator cuff tear.
- Ultrasound: used when MRI cannot be obtained (claustrophobia, pacemaker).
TREATMENT
Initial treatment for rotator cuff tears is usually nonoperative and should include the following conservative treatment measures:
- Rest: Because the shoulder is not a weight bearing joint like the knee, simply modifying one’s activities can improve symptoms
- Medications: Tylenol or anti-inflammatories can help with symptoms
- Injections: Steroid injections can provide temporary relief.
- Physical therapy: Range of motion exercises and strengthening can improve symptoms.
- Surgery: Recommended if these measures fail. Surgery is also recommended in most tears that occur as a result of trauma (acute tears).
SURGICAL TREATMENT OF IMPINGEMENT SYNDROME:
ARTHROSCOPIC ROTATOR CUFF REPAIR
Surgical treatment is very effective at repairing the rotator cuff and eliminating the underlying cause (impingement syndrome). Pain relief is excellent and strength is usually gained. UCLA repairs most tears arthroscopically through a minimally invasive approach.
Surgery is performed arthroscopically in the outpatient setting. General or nerve block anesthesia is administered. Three to four small incisions (5 mm) are made in the shoulder to allow a camera and specialized instruments into the shoulder. Inflamed bursa and bone spurs are removed arthroscopically, creating space for the rotator cuff muscles and eliminating impingement.
Suture anchors are utilized for the repair. Suture anchors are small metal or bioabsorbable screws that have two sutures each attached to them. The suture anchors are inserted in bone and the sutures are then used to sew the tendons to bone arthroscopically.
WHAT TO EXPECT
PREOP
- An MRI and X-rays of your shoulder will be ordered to evaluate for bone spurs, arthritis, and for the location, size, and reparability of the rotator cuff.
- If you have any medical problems, you will need a consultation with your PMD and/or cardiologist prior to surgery to ensure that you are safe for anesthesia.
DAY OF SURGERY/HOSPITAL STAY
- Nothing to eat or drink past midnight the night before surgery
- Surgery lasts 2-3 hours depending on complexity and is performed in the outpatient setting.
- Surgery is performed under general anesthesia or nerve block anesthesia (regional)
- Your arm will be in a sling postoperatively for 6 weeks.
- You will start exercises the day following surgery to move the shoulder passively.
POST-OP/REHAB
- Post-op visits:
- 2 weeks: suture removal, check motion and ensure proper performance of home exercises, start physical therapy
- 6 weeks: Discontinue Sling. Advanced physical therapy
- 12 weeks: Check range of motion and strength
- 24 weeks: final checkup.
- Physical therapy usually lasts 16 weeks and is divided into three phases
- 0-6 weeks: sling and passive motion
- 6-12 weeks: active motion
- 12-16 weeks: strengthening
- Even though most patients complete formal physical therapy 4-5 months post surgery. Final healing is probably not complete until one year after surgery.
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