|
Rotator Cuff Tears
(Courtesy of
www.aaos.org)
Description
A rotator cuff tear is a common cause of pain and
disability in the adult population. The rotator cuff is made up
of four muscles and their tendons. These combine to form a
"cuff" over the upper end of the arm (head of the humerus). The
four muscles - supraspinatus, infraspinatus, subscapularis, and
teres minor - originate from the "wing bone"(scapula), and
insert on the humerus. The rotator cuff helps to lift and
rotate the arm and to stabilize the ball of the shoulder within
the joint.
Normal Anatomy:
Risk Factors/Prevention
Rotator cuff tears are most common in people who are over
the age of 40. It may occur in younger patients following acute
trauma or repetitive overhead work or sports activity. Common
examples are:
· Workers who do overhead activities such as
painting, stocking shelves or construction
· Athletes such as swimmers, pitchers and tennis
players
A cuff tear may also happen with another injury to the
shoulder, such as a fracture or dislocation.
Symptoms
Symptoms of a rotator cuff tear may develop acutely or have
a more gradual onset. Acute pain usually follows trauma such as
a lifting injury or a fall on the affected arm. More commonly,
the onset is gradual and may be caused by repetitive overhead
activity or by wear and degeneration of the tendon. You may
feel pain in your shoulder that radiates down the side of your
arm. At first the pain may be mild and only present with
overhead activities such as reaching or lifting. It may be
relieved by over-the-counter medication such as tylenol or
ibuprofen. Over time the pain may become noticeable at rest or
with no activity at all. The MOST common symptom of rotator
cuff problems is NIGHT PAIN. Other symptoms may include
stiffness and loss of motion. You may have difficulty using
your arm to reach overhead to comb your hair or difficulty
placing your arm behind your back to fasten a button. When the
tear occurs with an injury, there may be sudden acute pain, a
snapping sensation and an immediate weakness of the arm.
Rotator Cuff Tear:
Diagnosis
Diagnosis of a rotator cuff tear is based on your symptoms,
Dr. Brady’s examination, X-rays, and imaging studies such as
MRI (magnetic resonance imaging). Dr. Brady will examine your
shoulder to see if it is tender in any area or if there is a
deformity. He will measure the range of motion of your shoulder
in several different directions and test the strength of your
arm. He will also check for problems with the AC (acromioclavicular)
joint.
If indicated, Dr. Brady may also examine your neck to make
sure that your pain is not coming from a "pinched nerve" in
your cervical spine and to rule out other conditions such as
osteoarthritis or rheumatoid arthritis.
Some of the signs of a rotator cuff tear include:
· Atrophy or thinning of the muscles about the
shoulder
· Pain when you lift your arm
· Pain when you lower your arm from a fully
raised position
· Weakness when you lift or rotate your arm
· Crepitus (crackling sensation / sound) when you
move your shoulder in certain positions
Plain X-rays of a shoulder with a rotator cuff tear are
usually normal or show a small bone spur. X-rays do a great job
at looking at bones however they do not show muscles / tendons
/ or other soft tissue. For this reason, Dr. Brady may order an
MRI study. This study can better visualize soft tissue
structures such as the rotator cuff tendon.
An MRI can sometimes distinguish between a full thickness
(complete) tear of the tendon and a partial tear. It can show
the doctor if the tear is within the tendon itself, or if the
tendon is detached from bone.
Treatment Options
Once a diagnosis of rotator cuff tear has been made, Dr.
Brady will discuss treatment options with you. In general there
are four treatment options.
Do nothing and live with the pain / weakness: This is
not cancer and will not kill you but living with the
discomfort and weakness can be quite difficult. Doing
nothing is always an option.
Anti-inflammatory medication / cortisone (steroid)
injections: This can help you live with your shoulder. The
goal is to reduce your pain. This option will not increase
your strength or repair the torn rotator cuff however.
Physical Therapy: PT can help maximize your strength. By
strengthening the muscles around the torn rotator cuff
muscle, your strength can improve substantially. This is
sometimes most beneficial in the case of a chronic rotator
cuff tear
Arthroscopic Rotator Cuff Repair: This option repairs
the torn tendon back down to the bone. After sufficient
rehabilitation, the goal is both to eleviate pain and to
restore strength.
Treatment Options: Arthroscopic Rotator Cuff Repair
Dr. Brady repairs ALL rotator cuff tears
arthroscopically. This means that instead of having to make a
large incision around the shoulder to reach inside the shoulder
and pull the rotator cuff back down to the bone, he performs
the entire procedure through small nicks in the skin and uses a
camera and small surgical instruments to repair everything in
the shoulder. Since the camera is extremely small he can
position the camera ANYWHERE in the shoulder and see things
much better this way. He is experienced in performing many
arthroscopic release procedures if your cuff tear is somewhat
large and immobile.
The primary goal of surgical treatment is pain relief and it
is quite effective. Over 90% of patients experience substantial
or total pain relief. The second goal is restoration of
strength. Strength restoration is dependant on a multitude of
factors. Dr. Brady typically recommends surgery if nonoperative
treatment does not relieve your symptoms. Surgery may also be
considered if the tear is acute and painful, if it is the
dominant arm of an active individual or if you need maximum
strength in your arm for overhead work or sports.
In the operating room, Dr. Brady will also remove any 'bone
spurs' within your shoulder. This is done at the same
time utilizing the same arthroscopic tools. Other
conditions such as arthritis of the AC joint or tearing of the
biceps tendon may also be addressed.
Arthroscopic picture of a rotator cuff tear
involving the supraspinatus (SS) and the Infraspinatus (IS)
tendons.
A grasper us used to pull the torn rotator cuff
tendons back to the bone where they belong.
Small screws are inserted into the bone.
Suture threads are attached to these screws and will be used to
repair the tendon back to the bone. The bone in this
picture is the pinkish-yellow tissue.
The sutures are tied using special arthroscopic
knot tying instruments
The final repair shows the blue sutures securing the
rotator cuff tissue (white) down to the underlying bone.
Rehabilitation
After surgery, the arm is immobilized to allow the tear to
heal. The length of immobilization depends upon the severity of
the tear. You will be given an exercise program to help regain
motion and strength in the shoulder. This begins with passive
motion. It advances to active and resistive exercises. Dr.
Brady may recommend that you work with a physical therapist.
Complete recovery may take up to 6 months.
A strong commitment to rehabilitation is important to
achieve a good surgical outcome. The doctor will advise you
when it is safe to return to overhead work and sports activity.
Research on the Horizon/What's New?
Dr. Brady utilizes dissolvable suture anchors. These are the
small screws that hold stitches in place or hold stitches down
to bone until the repair has healed and then they are absorbed
by the body. Research is also being done on "orthobiologic"
tissue implants. These promote growth of new tissue in the
body, and help with the healing process.
|
