• Rotator Cuff Tendon Tears / Shoulder Arthroscopy

      Rotator cuff tendon injury is a spectrum of disorders ranging from simple inflammation of the bursa (fluid sac that helps gliding between surfaces) to complete tears of the rotator cuff tendons.  The rotator cuff is a group of 4 tendons that attaches to the humeral head (the ball of the shoulder) and is responsible for rotation, elevation and stability of the shoulder.

      Mechanisms of Rotator Cuff Injury:

      • Trauma
      • Overuse: Some patients just wake up one day with symptoms but most are active and participate in overhead sports or activities and develop symptoms as a result of repetitive overuse.
      • Impingement: Some patients may have a bone spur that protrudes down from another bone called the acromion.  In time the bone spur can irritate the bursa, leading to bursitis and eventually wear into the rotator cuff and lead to a rotator cuff tendon tear.

      Symptoms

      • Patients are typically over 40 years of age
      • Weakness
      • Pain: Patients may develop pain with basic activities of daily living such as lifting a carton of milk, fastening a bra, tucking in a shirt, combing their hair and others. Patients may have pain with sport activities like throwing, serving tennis balls, and swimming. The pain can also interrupt sleep.
      • snapping/crackling with motion
      • stiffness.

      Evaluation by the Physician

      • Review of the patient’s symptoms and activities.
      • Physical examination: There are several specific maneuvers the physician will perform to the shoulder to help determine if a rotator cuff tendon tear is the cause of the patient’s pain.

      Imaging

      • X-rays are helpful when looking for bone spurs, calcium deposits and ruling out arthritis.
      • MRIs are designed to evaluate soft tissue such as the rotator cuff tendons, ligaments and cartilage.
      • Ultrasound devices are being used more frequently in the office to evaluate the rotator cuff tendons. Some advantages are that it can be done immediately, takes less time, and no issues of claustrophobia.

      X-ray Black arrows pointing to large bone spur emanating from the acromion and impinging on the bursa and rotator cuff tendons

      MRI: Showing  of a shoulder revealing a torn and retracted rotator cuff tendon.  Red arrow pointing to torn free edge of the rotator cuff tendon. Green arrow pointing to normal insertion site where the tendon should be attached.

      Non-Operative Treatment

      • Activity modification: Patients are advised to avoid overhead activities.
      • Physical therapy: Although therapeutic exercises will not heal a torn rotator cuff tendon they can improve the overall mechanics of the shoulder. Most commonly only one of the rotator cuff tendons is torn (supraspinatus), therefore strengthening the remaining rotator cuff tendons will help compensate for the torn tendon. This can lead to improved function and decreased pain.
      • Medication: Antiinflammatory medications (NSAIDS) can help relieve pain and inflammation. Patients with GI or cardiac disease need to consult a physician prior to taking these types of medications.
      • Steroid injection: An injection to the bursa is commonly performed to decrease pain. Limited use of steroid injections is recommended to avoid further damage to the tissues.

      Can rotator cuff tendon tears be treated non-surgically?

      Before we can answer this question, we need to review some of the science:

      • Rotator cuff tendon tears do not heal on their own.
      • 50% of rotator cuff tendon tears expand with time if not repaired.
      • The muscle attached to the torn tendon atrophies and contracts with time. These changes eventually become irreversible.
      • Rotator cuff tendon tears that have a delayed repair have poorer mechanical properties then those repaired early.

      Minimally Invasive Surgery / Shoulder Arthroscopy

      Recent advances in arthroscopic surgical techniques now allow specially trained orthopedic surgeons (Dr. Edmond Cleeman & Dr. Mark Klion) to repair torn rotator cuff tendons through minimally invasive techniques (usually 4 small portals around the shoulder). These procedures are usually performed with a regional anesthetic (the arm is numbed) and the patient goes home the same day.  Success rates are high in small tears but success diminishes with increasing tear size.

      • Repairing the tendon: The torn rotator cuff is reattached to the bone.  Sutures are arthroscopically placed through the torn rotator cuff tendon and fixed to the bone with implants called anchors. These anchors are non-metallic.
      • Addressing Impingement: Bony impingement issues (bone spurs) are also corrected arthroscopically.  The bony spurs are removed using high-speed arthroscopic burrs.

      Post Surgery Care:

      • Sling for 6 weeks
      • Ice or compression ice machine is applied to the surgical area.
      • Pain medication
      • Physical therapy
      • Recovery can take 4-6 months before patients are ready to return to sports

      Shoulder Anatomy


      Fig 1. Bony anatomy of the shoulder

      Fig 2. Soft tissue anatomy of the shoulder

      Fig. 3 Inflammed bursa and rotator cuff tendon tear

      Arthroscopic Rotator cuff Tendon Repair.

      Fig 4. Bursa is surgically debrided.

      Fig 5. Suture anchor placed into bone

      Fig 6. Rotator cuff tendon sewn back to bony insertion site.