Rotator Cuff Tear
What is the rotator cuff?
The rotator cuff is a group of four muscles (Supraspinatus, Infraspinatus, Subscapularis, and Teres Minor) that have a very important role in all movements of your shoulder. More specifically, they are involved in rotational movement (internal and external rotation) and elevation of the arm, as well as to help stabilize the glenohumeral joint (i.e. the shoulder ball-and-socket joint).
How is the rotator cuff torn?
A rotator cuff tear can either be acute (traumatic) or chronic (i.e. degenerative). Acute tears often occur secondary to a fall on an outstretched arm, after a shoulder dislocation, or when lifting a heavy object. Chronic tears are more common and tend to occur as we age. Years of repetitive shoulder use can result in wearing out of the rotator cuff tendon. People who do repetitive lifting or overhead activities (especially overhead athletes) are especially at risk. The development of bone spurs on the bone above the rotator cuff (Acromion bone) can also pinch and rub against the rotator cuff increasing the wear and tear phenomenon (see impingement syndrome). A worn out tendon is also prone to tearing with minor trauma given less force needed to tear the tendon.
Patients with acute tears may actually feel a sharp pain or even a "pop" during the time of the trauma. Degenerative tears may cause vague pain within the shoulder that can radiate down as far as the elbow, especially with lifting or overhead activities. Side sleeping on the affected shoulder often causes pain waking patients from sleep. Patients who have more significant or full thickness tears may also experience a weakness that makes it difficult to raise their arm.
X-rays are usually ordered first and may reveal bone spurs or calcium deposits within the rotator cuff tendon. Other radiologic studies such as an Ultrasound may be used to help characterize the tear, or in those patients who cannot have an MRI due to medical reasons. In those patients suspected to have full thickness tears or have enough pain that might warrant an injection or surgery, an MRI is often ordered to confirm the diagnosis and determine its severity. MRI can show the location and size of the rotator cuff tear, and can also provide insight into how long the rotator cuff has been torn.
Treatment of rotator cuff tears is not a straightforward issue, as many considerations must be taken into account. Primary considerations are the size of the tear (i.e. partial-thickness versus full-thickness), age of the tear, length of symptoms, pain severity, functional requirements, hand dominance, and age of the patient.
Non-operative management is the preferred first-line treatment for anything but a full thickness tear irrespective of age. This usually consists of activity modification (specifically avoiding overhead activities and heavy lifting) and Physical Therapy. The goal of Physical Therapy is to increase shoulder range of motion, strengthen the rotator cuff muscles and other stabilizers of the shoulder and improve shoulder function. Typically, Dr. Lee will recommend a physical therapy protocol for at least 6 weeks.
If either this nonoperative treatment does not provide satisfactory improvement, or if the patient has an unusual amount of pain, injections may be warranted. Based on the MRI, if the patient has significant inflammation without evidence of a partial tear, a steroid injection such as Cortisone may provide pain relief. However, if there is a partial tear, Dr. Lee feels a steroid injection may cause the rotator cuff to tear further due to the fact that steroids can weaken collagen/tendons. In these cases, treatment with biologics such as Platelet Rich Plasma may be warranted.
Acute full-thickness tears that present with significant weakness in raising the arm often requires surgery. Delaying surgery increases the risk of muscle atrophy (i.e. breakdown of muscle), fatty infiltration (i.e. muscle being replaced with fat), and tendon retraction (i.e. torn tendon ends being pulled further apart). Muscle atrophy, fatty infiltration, and tendon retraction all decrease the chance of a successful repair. Repair eventually becomes impossible in the advanced stages of these three conditions. Unfortunately, full thickness tears that are not repaired often result in progressively increasing pain and weakness, and ultimately arthritis of the shoulder.
Dr. Steven Lee performs an all-arthroscopic repair of the rotator cuff tendon. Arthroscopic repair is minimally invasive surgery that begins by making multiple small incisions overlying the shoulder. A small camera is then inserted through an incision into the shoulder joint, which displays a picture onto a television screen that Dr. Lee can view. Dr. Lee will repair the rotator cuff by re-attaching the tendon to the humeral head (i.e. ball of the shoulder joint) using special strong suture material that is then tightly secured into bone using small, specialized anchors. It is important to note that these anchors are not made of metal and will not set off alarms in airport security lines. A procedure called a subacromial decompression may also be performed in addition to your rotator cuff repair. This procedure is performed arthroscopically and involves using a small miniature burr to shave down the undersurface of the acromion. Dr. Lee may choose to just debride (i.e. cleanup) portions of the partially torn rotator cuff versus repairing the cuff. Decision to do this is case-specific and depends on what Dr. Lee is seeing within the shoulder joint when he first inserts the camera.
It is important to note that surgery may not be recommended in older patients with full-thickness tears who have minimal pain, good function, relatively preserved strength, low baseline functional demands, or in those patients who delayed their surgery too long as above. Some patients may be able to compensate for one of the rotator cuff muscles being torn by the other three rotator cuff muscles.
In the case of a partial tear that has failed non-operative management for at least 3 months, an arthroscopic debridement and subacromial decompression can provide relief.
Dr. Steven Lee has performed thousands of arthroscopies, is fellowship trained in Sports Medicine, is part of the teaching faculty for the Lenox Hill Sports Medicine Fellowship (which is the oldest sports medicine fellowship in the country), and is currently the Associate Director at NISMAT, which is the first institute in the country dedicated to sports medicine research. He has also authored a paper dedicated to Rotator Cuff Repair technique, which was honored as William A. Grana Award for Best Research.
Patients will be placed into a soft dressing and sling following shoulder surgery. Patients will continue to wear this sling until their first post-operative appointment 7-10 days following surgery. The dressing from the operating room can be removed 48 hours after surgery and the small incision sites covered with bandaids.
Patient will have their sutures removed at their first post-operative appointment and be advised to remain in their sling for an additional 3 - 4 weeks. Basic home exercise instructions will furthermore be prescribed and discussed at this appointment. The repaired rotator cuff needs time to heal prior to starting formalized Physical Therapy, hence the reason for staying in the sling for an additional 3 weeks.
Physical therapy usually begins 4 weeks after surgery and follows a strict protocol. This protocol will be given to you at your second post-op appointment. You will in turn give this protocol to your Physical Therapist for them to follow.
It is important to note that return to normal activity normally takes at least 6 months. It is furthermore common for patient to experience continued strength and functional improvement 1-2 years after surgery.
Immediate Post-Operative Instructions
Please refer to the following pages for more information:
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.