Repair of Rotator Cuff Tears: Surgery for shoulders with torn rotator cuff tendons can lessen shoulder pain and improve function without acromioplasty.
Edited By: Winston J. Warme, MD, Frederick A. Matsen III, M.D.
Last updated Wednesday, May 14, 2008
Figure 2 - Supraspinatus tear of the rotator cuff Figure 3 - Exercises for rotator cuff tears Review of the condition
Rotator cuff tears are common causes of shoulder weakness and pain that can often be improved by expert shoulder surgery.What are some general characteristics of rotator cuff tears? What are its usual manifestations? Individuals with rotator cuff tears usually notice weakness, pain, and
loss of the ability to use the shoulder for their usual activities.
Commonly, they have difficulty sleeping on the affected shoulder and
have a limited range of active motion. Some people with rotator cuff
tears notice a catching or grinding feeling when the shoulder is moved.
Rotator cuff tears usually get worse over time, but the rate of this
progression varies widely.What are the different types of rotator cuff tears? Rotator cuff tears may involve the entire thickness of the tendon
(full thickness rotator cuff tears) or they may be incomplete (partial
thickness).
Full thickness tears may involve only part of one tendon (usually
the supraspinatus). They may extend to become massive, involving
multiple tendons, as shown in the figure.
Rotator cuff tears may be degenerative (the defect arose in tendon
of poor quality) or they may be traumatic (the tear arose from a major
injury to otherwise healthy tissue). Cuff tear arthropathy refers to
the combination of a massive cuff tear and arthritis of the shoulder
joint. What else might be confused with or similar to rotator cuff tears? How can these be distinguished from the condition? Rotator cuff disease must be distinguished from shoulder arthritis,
arthritis of the acromioclavicular joint, subacromial bursitis, frozen
shoulder, and neck arthritis, each of which may produce similar
symptoms.
Shoulder arthritis usually causes pain and limited shoulder motion.
X-rays confirm the presence of arthritis. Arthritis of the
acromioclavicular joint usually produces pain localized to the top
front of the shoulder that is made worse by using the arm in front of
the body. Shoulder strength is usually normal. Subacromial bursitis may
cause catching and pain in the shoulder, but shoulder strength is
maintained. Frozen shoulder is characterized by shoulder stiffness, but
the shoulder is usually strong. Neck arthritis with nerve impingement
may cause shoulder pain and weakness that is worse when the head is
held in certain positions. In this case, electromyography may identify
the presence of nerve involvement in the neck. Some have used the term
"impingement syndrome" to refer to various types of cuff disease.
However, modern diagnostic approaches usually permit a more specific
diagnosis. How common is rotator cuff tears (statistics, demographics, risk factors)? Conditions of the rotator cuff are the most common cause of problems
of the shoulder. They are more likely to be found in people over the
age of 40, smokers, and individuals who have had multiple steroid
(cortisone) injections. People over the age of 40 who dislocate their
shoulders are likely to have cuff tears. Those who have a cuff tear in
one shoulder are likely to have similar problems in the opposite
shoulder.
How is rotator cuff tears diagnosed? What tests or exams may be used? A physician diagnoses rotator cuff disease by reviewing the
patient's history, performing a thorough physical examination of the
joint, taking the proper X-rays, and obtaining confirming imaging
studies (such as a shoulder ultrasound or MRI). The examination of a
shoulder with cuff disease reveals weakness or pain on exertion of the
shoulder against isometric resistance. Sometimes the shoulder is stiff
or noisy on movement.
X-rays of the shoulder are usually normal in the presence of cuff
disease--they are taken to exclude other problems. Rotator cuff tendons
do not show on ordinary X-ray examinations of the shoulder.
One method for diagnosis is ultrasound. In the hands of an
experienced sonographer, dynamic shoulder ultrasound is a quick, safe,
and reliable method for documenting the status of the rotator cuff
tendons. By reflecting sound waves off the tendons, sonographic images
are created as the tendons move. Defects in the tendons may be revealed
on these images. Magnetic resonance imaging (MRI) is another method for
imaging the rotator cuff tendons. One risk is that some patients become
claustrophobic during MRI examinations. A third method that has been
used to evaluate the integrity of cuff tendons is shoulder
arthrography. In this technique, dye is injected into the joint so that
leaks through the cuff can be seen on X-rays.
It is essential that the shoulder surgeon establish the diagnosis of rotator cuff before surgical treatment is considered. Can medications help rotator cuff tears? Medications
cannot help a torn tendon heal. However, mild pain-relieving
medications may make shoulders with rotator cuff tears more
comfortable. Cortisone (steroid) injections in the area of the cuff
tendons may lessen the discomfort from the cuff problem, but may also
weaken the tendon tissue. Multiple injections of steroids are
discouraged for this reason.Can exercises help rotator cuff tears? While prompt surgery is usually recommended for acute cuff tears in generally healthy shoulders, exercises
may be helpful in maintaining the flexibility and strength of joints
with long-standing cuff tears. In most cases, these exercises can be
done in the patient's home with little equipment. Shoulder exercises
are best performed gently several times a day on an ongoing basis. The
exercises are not dangerous if they are performed gently so that they
do not risk enlarging the cuff tear.
The figures show two examples of these exercises. The illustration
on the left shows the patient using the left arm to help lift the stiff
right shoulder in a forward direction. The illustration on the right
shows the patient using the left arm to gently stretch the stiff right
arm in external rotation using a yardstick.
Sometimes physical therapists suggest other types of therapy.
Patients should learn the possible risks of these approaches as well as
their costs and anticipated effectiveness.
Specifically, how is rotator cuff tears improved by rotator cuff surgery? When combined with a good rehabilitation effort, rotator cuff
surgery allows people to regain much of the lost comfort and function
in shoulders with cuff disease. In experienced hands, this procedure
can address the restricting scar tissue and roughness that frequently
accompany cuff disease. If the quantity and quality of the tissue is
good, surgery can help repair the tendon back to the bone from which it
has been torn. This is most likely to succeed soon after a cuff tear in
otherwise healthy shoulders of non-smokers who have not had multiple
cortisone injections.
Rotator cuff surgery can improve the mechanics of the shoulder, but
cannot make the joint as good as it was before the cuff tear. In many
cases, the tendons and muscles around the shoulder have been weakened
from prolonged disuse before the surgery. The tissue may be
insufficient for a strong repair. In such cases the mechanics of the
shoulder may be improved by carefully smoothing out the cuff area and
moving the shoulder immediately after surgery so that new scars are not
formed.
If the cuff is repaired, it takes months before the tendon is
strongly healed to the bone. During this time, strengthening exercises
must be avoided so that healing is not impaired. After the healing, it
may take months of gentle exercises before the shoulder achieves
maximal improvement.
The effectiveness of the procedure depends on the health and
motivation of the patient, the condition of the shoulder, and the
expertise of the surgeon. When performed by an experienced surgeon,
rotator cuff surgery usually leads to improved shoulder comfort and
function. The greatest improvements are in the ability of the patient
to sleep, perform activities of daily living, and engage in non-contact
recreational activities.
Repair of Rotator Cuff Tears Surgery for rotator cuff tears at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-7416 to make an appointment.
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