The Rotator Cuff
The rotator cuff is a large tendon comprised of four muscles which combine to form a “cuff” over the upper end of the arm, the head of the humerus. The four muscles—supraspinatus, infraspinatus, subscapularis and teres minor—originate from the “wing bone,” the scapula, and together form a single tendon unit that inserts on the greater tuberosity of the humerus.
The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint.
What causes a rotator cuff tear and how would I know if I have one?
A rotator cuff tear may result from an acute injury such as a fall or may be caused by chronic wear and tear with degeneration of the tendon. Impingement of the front of the scapula, the acromion, on the tendon is believed to be a major cause of cuff tears in individuals older than 40 years.
Typically, you will feel pain in the front of your shoulder that radiates down the side of your arm. It may be present with overhead activities such as lifting or reaching. You may feel pain when you try to sleep on the affected side. You may note weakness of your arm and difficulty with routine activities such as combing your hair or reaching behind your back.
If the tear occurs with injury you may experience acute pain, a snapping sensation, and immediate weakness of the arm.
If I have a painful rotator cuff and keep using it, will this cause further damage?
A rotator cuff tear can extend or get larger over time. This can occur with repetitive use or a re-injury. It is common for patients with known rotator cuff disease to have acute pain and weakness following a minor injury. This likely represents extension of an existing tear.
If you know you have a rotator cuff tear, then worsening pain and decreasing strength may mean the tear is getting larger.
When should I see a doctor for a rotator cuff tear?
If you have injured your shoulder or have chronic shoulder and arm pain, it is best to see your orthopaedic surgeon. He or she can then make a diagnosis and begin treatment. The doctor may recommend a diagnostic study such as MRI (magnetic resonance imaging) to confirm the diagnosis.
Early diagnosis and treatment of a rotator cuff tear may prevent symptoms such as loss of strength and loss of motion from setting in.
Can a rotator cuff tear be healed or strengthened without surgery?
Many rotator cuff tears can be treated nonsurgically. The aim is to obtain improvement in shoulder function.Anti-inflammatory medication, steroid injections, and physical therapy may all be of benefit in treating symptoms of a cuff tear. The goals of treatment are to relieve pain and restore strength to the involved shoulder.
Non operative treatment does not lead to healing of the torn rotator cuff tissue but individuals do experience an improvement in pain symptoms. The shoulder function and movement however stays sub-optimal.
Each of the methods available has its own advantages and disadvantages, all have the same goal: getting the tendon to heal.
You may have other shoulder problems in addition to a rotator cuff tear, such as osteoarthritis, bone spurs, or other soft tissue tears. During the operation, your surgeon may be able to take care of these problems, as well.
The three techniques most commonly used for rotator cuff repair include traditional open repair, arthroscopic repair, and mini-open repair. In the end, patients rate all three repair methods the same for pain relief, strength improvement, and overall satisfaction.
A traditional open surgical incision (several centimeters long) is often required if the tear is large or complex. The surgeon makes the incision over the shoulder and detaches the shoulder muscle (deltoid) to better see and gain access to the torn tendon.
During an open repair, the surgeon typically removes bone spurs from the underside of the acromion (this procedure is called an acromioplasty). An open repair may be a good option if the tear is large or complex or if additional reconstruction, such as a tendon transfer, is indicated.
Open repair was the first technique used for torn rotator cuffs. Over the years, new technology and improved surgeon experience has led to less invasive procedures.
During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.
Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.
All-arthroscopic repair is usually an outpatient procedure and is the least invasive method to repair a torn rotator cuff.
The mini-open repair uses newer technology and instruments to perform a repair through a small incision. The incision is typically 3 to 5 cm long.
This technique uses arthroscopy to assess and treat damage to other structures within the joint. Bone spurs, for example, are often removed arthroscopically. This avoids the need to detach the deltoid muscle.
Once the arthroscopic portion of the procedure is completed, the surgeon repairs the rotator cuff through the mini-open incision. During the tendon repair, the surgeon views the shoulder structures directly, rather than through the video monitor
If you are active and use your arm for overhead work or sports, then surgery is most often recommended because many tears will not heal without surgery.
At what point does a rotator cuff tear require surgery to fix it?
Surgery is recommended if you have persistent pain or weakness in your shoulder that does not improve with nonsurgical treatment. Frequently, patients who require surgery will report pain at night and difficulty using the arm for lifting and reaching. Many will report ongoing symptoms despite several months of medication and limited use of the arm.
Surgery is also indicated in active individuals who use the arm for overhead work or sports. Pitchers, swimmers, and tennis players are common examples