Rotator Cuff Injuries | A Look into the Symptoms and Treatments
Rotator cuff injuries are the most frequent causes of shoulder pain and aren’t necessarily caused by an injury. Most often rotator cuff pain comes from a degenerative, attritional process. Other causes include degenerative tears, genetic causes, inflammatory diseases, age and activity related pain. Each patient that presents with rotator cuff pain has a different story. Some patients report pain after falling down and some can wake up one day with pain in the shoulder that never goes away.
WHAT IS THE ROTATOR CUFF?
The rotator cuff is a group of four muscles and tendons that attach to the humerus, which is the “ball” that makes up the ball and socket shoulder joint. They are called the supraspinatus, infraspinatus, subscapularis and teres minor. These four muscles act together to initiate movement and maintain stability of the shoulder, in activities such as lifting and throwing a ball. These muscles work along with the deltoid and pectoral muscles to give fluid motions and strength.
WHAT ARE THE MOST COMMON ROTATOR CUFF INJURIES?
The rotator cuff can hurt for various reasons and the majority of causes are chronic and degenerative in nature, as opposed to a one-time injury. The amount of pain patients have from rotator cuff injury can vary greatly. Surprisingly, patients with inflammation or a small, partial tear can have much more pain than patients with large, full tears. In fact, there are probably more patients with full tears that have no idea they have a tear then patients who have pain and discover they have a partial tear. This is why every patient with rotator cuff injury is unique and we must customize our treatment for each patient and their cause of pain. There is no “cookbook” answer on how to cure your rotator cuff pain.
Rotator cuff injuries include:
1. Tendinosis – the most common cause
3. Partial tears of the rotator cuff
4. Full tears of the rotator cuff
5. Calcific tendonitis – one of the most painful causes of shoulder pain
Tendinosis represents the aging process of the rotator cuff tendons. Like all rotator cuff injuries, the supraspinatus tendon is the most commonly involved. Why an aging tendon hurts is still unclear. Most likely small partial tears develop in the tendon as it breaks down and gives off signals of pain to the shoulder.
Tendonitis is inflammation around the tendon and most often occurs in younger patients due to overuse in work or sports. A mechanical irritation occurs around the tendon as it fatigues from doing too much movement. Often, tendonitis is a result of the shoulder being unstable or loose, as the rotator cuff works overtime to keep the shoulder stable (in the socket) and wears down.
Partial tears of the rotator cuff most often occurs with wear and tear, similar to an old pair of jeans wearing at the knees. The pain from partial tears can be significantly higher than that of a full tear. Recent research states that this may be a result of the attempt at the shoulder to heal the tear giving off inflammatory markers causing pain.
Full tears of the rotator cuff are extremely common. Studies show that at least 25 percent of patients by the age of 65 and 50 percent by the age of 80, have rotator cuff tears. Many patients don’t know the tear is present; this is confirmed through volunteer MRI studies of patients with no shoulder symptoms. Those with symptoms usually present with pain, weakness, difficulty sleeping and everyday tasks becoming very difficult.
WHEN IS SURGERY NEEDED FOR ROTATOR CUFF INJURY?
The decision to perform surgery for rotator cuff tears depends on many factors like age of the patient, size of the tear, quality of the muscle and tendon on the MRI, as well as functional goals of the patient. Most patients with tendinosis, tendonitis and partial tears respond to non-surgical care including medications, rest, therapy and sometimes cortisone injections.
One would think patients with full tears, always require surgery because without repair, the tendon will never heal, as it is pulled away from its attachment on the bone. However, depending on the age of the patient and the tear, many people can recover by leaving the tear alone. Repair of the tendon is not always needed for patients over the age of 65.
Younger patients, especially with acute traumatic full tears, are considered for surgery without attempting extended conservative care. Unfortunately, there is a window of opportunity beyond which the tendon may not be fully repairable due to retraction of the tendon and atrophy of the muscle.
HOW IS ROTATOR CUFF SURGERY PERFORMED?
Orthopaedic Surgeons treat rotator cuff tears with a camera arthroscopy, looking into the shoulder on a TV screen. Due to the minimally invasive technique; patients can go home the same day. The goal is to place the tendon back to its origin and sew it in place, using special suture anchors to hold the tendon in place until it heals to the bone. As we age, the blood supply to the tendon is not great and can get worse; the poor biology can lead to failure, challenging the surgery.
We have been working a great deal on improving the healing rates for repair by improving the biology. There are patient-related factors that also worsen the chance of healing, such as smoking and diabetes.
Ways we are improving rotator cuff surgery:
1. Stronger sutures
2. Better repair techniques
3. Using stem cells derived from the patients bone marrow
4. Collagen Patch sewed into the repaired tendon
HOW LONG DOES IT TAKE TO RECOVER FROM ROTATOR CUFF SURGERY?
Recovery from arthroscopic rotator cuff repair goes in stages. The first stage, which lasts around three months, centers around protecting the tendon repair so it can heal. This requires limited, active motion for the first six to eight weeks with protection in a sling. For small tears with good quality tendon, you may be allowed to get out of the sling by four weeks, but large, massive tears may require a sling for more than eight weeks with no motion of the shoulder.
Early motion of the shoulder can be initiated with smaller tears but for large tears, we recommend to go slowly. Stiffness may occur, but as I tell my patients, I can solve your stiffness with therapy and maybe a manipulation (a procedure where we move the shoulder under anesthesia) but I can’t solve the multiple repeat tearing of a rotator cuff. Recent research has shown that those patients that are stiffer early on may have better results. The stiffness actually protects the tear.
Don’t worry too much if you aren’t sent to therapy right away. Be patient and allow the tendon to heal.
The ultimate result can take up to a year after the repair. This is when your final strength and range of motion all comes together. By six months, most people are doing well; they can work, have a catch and be very active. However, some activities like lifting overhead and playing tennis, can take longer, depending on your progress and the size of the tear.
The Collagen Patch we have been using to assist in the healing of the tendon allows a little earlier motion and more robust healing of the tendon and ultimately, moving the timeline up a little bit to recovery.
If you need rotator cuff repair, don’t wait too long. Remember, there is a window of opportunity for a good repair. Waiting even six months can turn a small tear into a massive tear, making repair less predictable and recovery a lot longer.
In this video, Dr. Jonathan Hersch discusses a typical arthroscopic repair of the rotator cuff . In addition he uses a biological enhancement collagen patch to improve the chance of healing.