Rotator Cuff tears can be very painful and are a common cause of limited shoulder function. People with rotator cuff disorders often have pain or weakness when trying to play golf or tennis, throw a ball, fish, work in the yard, or do any kind of overhead activity. You may have difficulty sleeping on your side because of pain at night. Or, you may have trouble reaching behind your back to reach your billfold or bra. The problem may start suddenly, after a fall, after reaching into the back seat of the car to get a heavy briefcase, or when trying to catch or lift a heavy object. Alternatively, it may come on gradually with repetitive overhead shoulder activities at work or play with no obvious single injury.
The pain generated from the rotator cuff is usually felt on the front or side of the shoulder, but it can also be felt around the shoulder blade. Sometimes, the pain moves up into the neck or down the arm towards the elbow. Rarely does pain from the shoulder go past the elbow, but it can in some instances.
Rotator cuff disorders range from tendonitis to partial tears to full thickness tears, when the muscle is completely detached from the bone. The rotator cuff is a group of four muscles that surrounds the shoulder and functions to provide the strength and support to perform overhead activities. This group of muscles is precariously situated between the shoulder blade and collarbone above and the shoulder joint below. Some people have a spur on the underside of the shoulder blade and collarbone which pinches the rotator cuff and can cause inflammation or tearing of the rotator cuff. This is frequently known as impingement and can be seen with tendonitis, partial tears, or full thickness rotator cuff tears.
Early treatment of rotator cuff disorders may include physical therapy, anti-inflammatory medication, or a cortisone injection into your shoulder. These might completely resolve your symptoms. Physical therapy for the spectrum of rotator cuff disorders begins by focusing on the muscles around your shoulder blade and core, including your abdominals and low back, and then works into strengthening your rotator cuff muscles. After several visits with the therapists here or at another location, you can complete much of the therapeutic exercises on your own at home. Anti-inflammatory medicine can reduce the swelling that accompanies rotator cuff tendonitis and can help with the pain. Over-the-counter and prescription medications are both useful. Additionally, your doctor may offer you a cortisone shot on the day of your visit in an attempt to bring you pain relief right away. The injection is actually a mixture of cortisone, a steroid similar to a chemical your own body makes, and lidocaine, a numbing medicine that may take your pain away within minutes of the injection. The injection is placed inside your shoulder, just on top of the rotator cuff. This injection may relieve your pain permanently. If not, the injection can be repeated. Numerous injections are to be avoided, as they may only mask a problem that needs more definitive treatment.
Arthroscopic Rotator Cuff Repair:
If you continue to have pain or if you cannot get back to your normal activities, your doctor may offer you a surgery known as arthroscopic rotator cuff repair. This procedure uses specially designed instruments to sew the torn rotator cuff muscle back to the bone. This is all done through three or four ¼ inch incisions around the shoulder. Using a pencil sized digital camera inserted into your shoulder for the duration of the surgery, the doctor views the action on a high definition flat screen monitor.
This is a same-day surgical hospital which goes on here at the hospital or at a nearby outpatient surgical center. You may spend one night in the hospital for pain control and antibiotics. You will be seen by an anesthesiologist prior to surgery to discuss the option of putting another kind of injection in your shoulder so that your whole arm goes to sleep prior to the surgery and stays asleep for 12 to 24 hours afterwards. Additionally, you will go to sleep with general anesthesia for the entirety of the surgery. The surgery takes 1 to 2 hours. When you wake up, you will have a sling and pillow stabilizing your shoulder. You will stay in the recovery room until your pain is controlled and you are ready to leave for home or be admitted to the hospital overnight.
During the operation, your surgeon will use sutures to sew the torn muscle and tendon back down to the bone where it was originally attached. Those stitches hold the rotator cuff down to bone for the next three months while the two grow and heal back together. It takes three months for that to happen, and that is why your activities will be quite limited during that same time span. Rotator cuff tears come in four different sizes, small, medium, large, and massive, based upon how many tendons of the 4 muscles are torn.
Small tears involve less than one of the 4 muscles. Usually this is the supraspinatus, the muscle at the top of the rotator cuff, which sits just under the spur on the shoulder blade, and is usually the first muscle to tear. Partial tears are included in this category as well. Small rotator cuff tears can be fixed arthroscopically using 1 to 2 bone anchors and 2 to 4 stitches. Medium sized rotator cuff tears involve at least one but less than two of the four rotator cuff muscles. This usually includes the supraspinatus and infraspinatus muscles. Arthroscopic rotator cuff repair of medium sized tears can be accomplished with 2 to 4 anchors and 4 to 8 stitches.
Large and massive rotator cuff tears involve at least two, but sometimes three or all four rotator cuff muscles, being torn from the bone. Repairing these tears is far more difficult, but a great repair can be accomplished arthroscopically. In the past, people may have been told their rotator cuff tears were too large to be repaired. Sports medicine doctors specializing in shoulder arthroscopy can recognize the pattern of the tear and mobilize the edge of the torn muscle to complete an arthroscopic repair of large and massive tears. Additionally, some people may benefit from a patch augmentation of their repair.
Immediately following surgery, shoulder and arm will be stabilized in a sling and pillow. Ice packs or a “cryocuff” will be applied to your shoulder to limit the swelling and pain. Your initial dressing will become soaked with blood tinged fluid. The following morning, remove your dressing and cover each incision with a simple band aid. Your first appointment will likely be just a few days after surgery, and your skin sutures will be removed at that time. Until your skin sutures are removed, do not get your shoulder wet. You can use rubbing alcohol to clean your shoulder if you like.
Rehabilitation and physical therapy are critical for a successful outcome after an arthroscopic rotator cuff repair. Immediately following surgery, you can begin moving your hand, wrist, and elbow. You will receive your first therapy instructions or prescription at your first postoperative visit. Just as no two people are identical, no two arthroscopic rotator cuff repairs are identical, and so too shall each person’s rehabilitation be unique. As a general guide, for the first six weeks following surgery, you are allowed passive motion only in your operative shoulder. Gravity and your good arm will be used to move your operative shoulder. For the second six weeks after surgery, you can begin active motion and your operative shoulder begins to help with motion. Only three months after your surgery, when the torn muscle has healed back down to the bone, will you be allowed to begin strengthening for your rotator cuff. If you try to add strengthening too soon, the stitches holding the repair will come loose.
For the first three months following surgery, your activities are very limited. It usually takes another three months after that to get back to your full activities and sports. Your doctor will follow your progress closely and allow you to resume activities when you can do so in a safe manner. Expect to see your doctor two days, two weeks, six weeks, three months, six months, and twelve months after your surgery.
Outcomes of Arthroscopic Rotator Cuff Repair:
Success rate from arthroscopic rotator cuff repair depends on what is being measured. Patient satisfaction is the most common reported outcome from arthroscopic rotator cuff repair. Patient satisfaction is measured with standardized tests based upon patient responses to questions regarding their pain levels following surgery and their ability to carry out daily household, work, and sporting activities. Additional data is derived from physician measures of shoulder motion and rotator cuff strength.
Patient satisfaction is rated excellent and good for 93 to 97% of patients after arthroscopic rotator cuff repair in recent studies from Flurin et al in Arthroscopy 2007, Burns and Snyder in Journal of Shoulder and Elbow Surgery (JSES) 2008, and Charosset et al in American Journal of Sports Medicine (AJSM) 2007.
Success measures of patient satisfaction after rotator cuff repair depend upon age. Looking specifically at patients over 62 years of age, 87% had good to excellent results in a study by Grondel and Savoie in JSES 2004. Whereas, 100% of patients less than 40 years old had pain relief and 95% had improved function after arthroscopic single row repair in Krishnan Arthroscopy 2008.