By Derek S. Shia, M.D.
Rotator cuff tears are one of the most common orthopedic problems and effect more than 17 million persons annually in the United States. The rotator cuff is an essential group of four muscles that control shoulder motion and contribute to the concentric reduction of the glenohumeral joint. Rotator cuff tears have a tremendous effect on a patients’ ability to perform athletic activities such as tennis, golf, and softball but can also affect simple activities of daily living such as sleeping, brushing teeth, and combing hair. Not all rotator cuff tears occur due to a traumatic incident and many patients may be living with a painful shoulder as a result of a rotator cuff tear without knowing it. There are various treatment options available to patients depending on their age, activity level, size of tear and the length of time that the tear has been present.
There are two principle populations that are effected by rotator cuff tears. The first is young patients that have experienced a significant traumatic event that causes the rotator cuff to tear. The event that causes this is usually a high energy injury and patients complain of an immediate change in their ability to use their arm. The second group of patients is an older population that typically cannot recall a traumatic event. These patients often have an insidious onset of shoulder pain and weakness. They complain of an inability to perform activities above shoulder height such as washing their hair or lifting dishes up to high shelves as well as pain reaching behind themselves. Night pain is also very common and patients commonly seek treatment because they have a difficult time sleeping.
While these two groups make up the majority of patients there is certainly an overlap between these patients groups. Patients that need to be closely evaluated include patients over the age of 45 with a shoulder dislocation as well as patients who fall without radiographic evidence of a fracture but with weakness.
The incidence of rotator cuff tears is very strongly correlated with a patients’ age. Several studies have been recently published investigating this relationship. One of these studies utilized ultrasound to determine the prevalence of rotator cuff tears in 237 asymptomatic individuals. They found that age was strongly correlated with the prevalence of a full thickness rotator cuff tear. None of the patients age 40-49 demonstrated rotator cuff tears, patients who were age 50-59 demonstrated a 10% prevalence of a full thickness rotator cuff tear, patients age 60-69 demonstrated a 20% prevalence and patients older than 70 had a 41% prevalence of a full thickness tear. The importance of this study demonstrated the relationship between age and the likelihood of the presence of a full thickness rotator cuff tear in patients with no complaints of shoulder pain or weakness. In a related study 588 patients who had unilateral shoulder pain had the opposite shoulder examined with ultrasound. This study demonstrated a high incidence of rotator cuff tears in older individuals with 50% of patients over the age of 65 demonstrating a full thickness rotator cuff tear in the opposite shoulder that was asymptomatic.
It is important to consider the specific patient in terms of their functional status and also the natural history of untreated rotator cuff tears when contemplating various treatment options. Unfortunately, there is no evidence that rotator cuff tears can spontaneously heal without surgical intervention but depending on the patient and the size of the tear it is possible to make a rotator cuff tear asymptomatic. In a recent study investigating the natural history of non-surgically treated rotator cuff tears that were followed for 5 years, no tears showed any evidence of healing. Of the patients that became symptomatic again after a trial of non-operative management 50% of those patients had an enlargement of the tear. Of the patients that remained asymptomatic over the 5 year period, 20% had an enlargement of their tear. Of the patients whose tear increased, the average increase in size of the tear was 30%.
When considering that rotator cuff tears do not heal without surgical intervention it is important to think about the implications for the patient. When a rotator cuff tear does occur, irreversible changes of the muscle can begin within the first three months after an injury. Without the proper length/tension relationship fatty infiltration will begin in torn rotator cuff muscles. This process results in the replacement of the normal muscle tissue with fat, causing a permanent change in the elastic properties of the muscle tendon unit. This change is irreversible and can affect both a patients’ outcome after surgery and result in a rotator cuff being irreparable at the time of surgery. Various studies have investigated fatty infiltration after a rotator cuff repair and they have found these changes do not reverse even after repair of the tendon.
The physical exam is one of the most important parts of the patient evaluation and is instrumental in obtaining the correct diagnosis. Inspection of the shoulder should include evaluation of any atrophy along the scapular spine which is often indicative of a chronic rotator cuff tear.
Evaluation of a patients shoulder range of motion is vitally important in determining the correct diagnosis. Shoulder motion comes both from the glenohumeral joint which is responsible for 2/3 of the overall motion and the scapulothoracic joint which is responsible for the remaining 1/3 of overall shoulder motion. It is important to separate these two motions to detect pathology in the shoulder joint. Scapular kinematics are often abnormal following rotator cuff injuries and can be seen when evaluating the scapula during shoulder range of motion. The assessment of active and passive range of motion is also critical. Loss of both active and passive range of motion is often indicative of an adhesive capsulitis while loss of only active range of motion is often suggestive of rotator cuff pathology.
While there are a multitude of described tests for evaluation of the rotator cuff I have included some of the most common and helpful ones for detecting rotator cuff pathology.
The empty can test helps to evaluate the supraspinatus, the most commonly involved muscle in rotator cuff pathology.
Test of external rotation strength with the shoulders in internal rotation will help evaluate the infraspinatus.
The lift off test will help evaluate the function of the subscapularis.
The hornblower test will help evaluate the teres minor and is often only positive in massive rotator cuff tears.
Evidence of massive rotator cuff tears include a positive drop arm sign, which is the inability for a patient to hold their shoulder in external rotation, a positive hornblower test, as well as a pseudoparalysis of the shoulder when a patient is unable to actively lift their shoulder to 90 degrees.
Radiographs are an important modality when examining pathology around the shoulder and can suggest rotator cuff pathology. This xray demonstrates chronic rounding of the greater tuberosity often seen in long standing rotator cuff tears. It also demonstrates superior translation of the humeral head relative to the glenoid and gapping of the glenohumeral joint. Other pathology that can be appreciated by radiographs include both arthritis and calcific tendonitis which can sometimes present similarly to a rotator cuff tear.
MRI is an integral modality in the evaluation of a rotator cuff tear and adds important information regarding the extent and treatment of the tear. Choices between open and closed MRI’s are a common discussion with patients and are often driven by patient choice, body habitus and difficulty with claustrophobia. While open MRI’s continue to improve, closed MRI’s utilize a larger magnet and provide a clearer picture of all the involved pathology and improves the ability to make an accurate diagnosis.
An MRI can help determine the size of the tear and which tendons are involved, it can demonstrate the amount of retraction of the tendon and the amount of fatty infiltration. All these factors are important for determining the likelihood that a tear is repairable and whether it will heal.
There are various non-operative treatment options including activity modification, NSAIDS, physical therapy, and corticosteroid injections. The goal of these treatments is to reduce pain, increase range of motion, and improve function. The goals of physical therapy are to strengthen the remaining rotator cuff, improve scapular kinematics that are often abnormal after a rotator cuff tear, and strengthen scapular stabilizers. Physical therapy also works to improve range of motion, and promote functional return to normal activities.
The use of corticosteroid injections for rotator cuff disease is commonly used. The use of corticosteroids has been extensively studied and through multiple studies and meta-analyses have demonstrated limited efficacy in the long term treatment of rotator cuff disease. One benefit that has been shown is an improvement in pain levels in patients in comparison to placebo over the short term.
There are downsides to repeated corticosteroid injections with a theoretical reduction of overall tendon strength. Basic science research have predominated these studies and have even demonstrated increased type III collagen expression after only a single injection. For this reason while a single corticosteroid is often considered, multiple injections should be judiciously utilized. Multiple injections over time are often reserved for patients with limited functional goals and inability to undergo surgical intervention.
Surgical intervention for a repairable tear can be treated arthroscopically in the vast majority of cases. The advantages of an arthroscope versus an open repair includes several things including the ability to fully evaluate and treat any additional intra -articular pathology, preserve the deltoid muscle, and allow full access to the shoulder. Controversy continues to exist regarding the optimal surgical construct for the treatment of rotator cuff tears and whether a single or a double row repair best treats the pathology. A double row repair provides a more anatomic reconstruction of the rotator cuff footprint and may lead to lower rerupture rates in comparison to single row repairs in larger tears. This is currently a hotly debated topic and while basic science studies demonstrate benefits, functional differences have not been demonstrated to be statistically significant between either repair type in clinical studies.
Arthroscopic rotator cuff repair is performed as an outpatient procedure and normally takes between 1- 2 hours depending on the size of the tear and any concomitant pathology that needs to be addressed. The post-operative regimen typically involves a sling for the first 4 weeks. For smaller tears immediate motion is begun and for larger tears there is a period of immobilization. Strengthening is started at 12 weeks with gradual return to normal function. There are very good reported outcomes in the literature following rotator cuff repair with good alleviation of pain and return to functional status.
For certain patients the size and chronicity of their tear may not allow a primary repair. For these patients depending on their age and functional status various treatment options are available. These include tendon transfers including latissiumus dorsi and pectoralis major transfers. These are primarily used in younger patients with painful large chronic tears but with good function. The second treatment option is the reverse total shoulder replacement.
This option is reserved for older patients with a chronic irreparable rotator cuff tear and poor shoulder function. This option through a replacement of the shoulder joint eliminates pain and improves shoulder function.
Several factors have been demonstrated in the literature to negatively affect the functional outcome of patients following rotator cuff repair, these include: smoking, diabetes, patient age, the size of the rotator cuff tear , whether the rotator cuff tear is full thickness or partial thickness, and the degree of fatty infiltration. Some of these factors cannot be controlled but early diagnosis and treatment can avoid some of these pitfalls.
While no treatment algorithm is without exceptions this is a generalized way to think about rotator cuff tears and their treatment. Partial thickness tears have some risk of enlarging but a trial of non-operative management is indicated to see if a patient will do well without surgery. The second class of patients is the young patient who has a full thickness tear or any patient with an acute tear. In this patient population there is more downside to delaying surgery in that the tear will not heal itself, it may enlarge, and that the rotator cuff may undergo irreversible fatty infiltration. In this patient population surgery is indicated. The third category is elderly patients with a chronic rotator cuff tear. This is another population when waiting will have little impact on the patients’ outcome and non-operative treatment should be attempted.
Rotator cuff tears are extremely prevalent and have a significant impact on the patients who have them. A careful physical exam, good imaging and understanding of rotator cuff pathology and its natural history are instrumental in obtaining the correct diagnosis and developing the appropriate treatment course for a patient with a rotator cuff tear. While non-operative treatments are commonly utilized initially there are many minimally invasive treatment options available if surgery is necessary and good to excellent results are common following intervention.
© 2012 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author
By Alan M. Reznik, M.D., MBA
There is a lot of excitement about “evidence-based” medicine these days. It is as if clinical research was absent in the past. We all know medicine is not the “Wild West” as some would portray it. Just the same, it is often helpful to point out new data that will be helpful in guiding treatment options and revisit good old data to stay the course. To that end, this is aimed at updating you on some of the recent evidence that may have sparked some discussion and may help you talk to your patients. In practice now for almost 25 years, adding a seasoned understanding to this data may also be helpful to you in your daily practice. The most important “take away message” here is that the data needs to be applicable (to the patient in front of you today) in order to make sense. There is so much on the web that confuses our patients. They just don’t know what applies to them. It is our unique responsibility to help them understand the subtle differences that is the essence of clinical acumen.
A general word or two about rotator cuff repairs: It is clear now that arthroscopic repair is the standard for almost all tears. It is also clear that tears come in many sizes and shapes. Most recent evidence-based article was in JBJS in Jan of 2014 issue (A Prospective Randomized Trial of Immobilization Compared with early motion By Jay D Keener, et al. JBJS 2014;96:11-19) talks about early rehab for tears (small to medium in size). It showed that early (protected) motion in a guided rehab program (as in our office) offers better function at 3 months of prolonged immobilization even though there is no statistical difference at 24 months in the two groups. In 114 of the 124 patients seen at 30 month follow up 92% of the tears were healed. In practice, the better three-month results mean an earlier return to light selected work (heavy laborers and workman’s comp are separate issues) and hence for my average patient the early motion program a real advantage. Here as in other studies a “no significant difference” in final outcomes is not necessarily the full story. Larger or very large tears present a different set of issues, don’t heal as well and present a real challenge when addressed later in their course. A new acute traumatic large tear is always best treated earlier than later.
After much discussion over the past three decades about the best way to treat clavicle fractures, a study published in the Sept. 4 issue of the Journal of Bone & Joint Surgery compared nonsurgical treatment, open reduction and plate fixation for midshaft displaced clavicle fractures. As reported in a prior newsletter, in a good evidence-based article by: C.M. Robinson, FRCSEd(Tr&Orth); et al.: Open Reduction and Plate Fixation versus Non-operative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter, Randomized, Controlled Trial: J Bone Joint Surg Am, 2013 Sep 04;95(17):1576-1584 goes a long way to answer this question.
According to the results of this study, improved outcomes and reduced rate of nonunion after acute displaced, midshaft clavicle fractures was associated with internal fixation using plates. It is important to note that after excluding nonunions from analysis, the authors found no significant differences in DASH or Constant scores at any time point during the study period. The implication of this finding was nonunion (the failure of healing) was the prime driver of the poor outcomes and 16 times more likely in the nonrepaired group. The results for displaced mid shaft fractures are therefore improved when the bone is fixed with a plate (preferably earlier, within two weeks of the injury) and the complications of a non-union can be avoided.
Also in the January issue of JBJS there is a comprehensive review of AC joint separations. (Xinning, Li, et al JBJS 2014; 96:73-84. This is more commonly known to most of us and our athletic patients as a “shoulder separation.” Usually it happens after a fall onto the outer edge of the shoulder as opposed to a “shoulder dislocation” (the ball is knocked out of the socket) usually after a forceful external rotation of the arm in an overhead position. For shoulder separations, in most cases, we see the deformity at the end of the collarbone. In higher-grade injuries the tip of the collarbone can “tent” the skin. There are many types of separations. They are most commonly graded one through six. Lower grades, grades one and two, minimally displaced and not tenting the skin, can be treated non-operatively and if there are symptoms at a later date they can be addressed nicely arthroscopically. Grade three is more displaced and controversial. Operative verses nonoperative treatment (with accepting a visible deformity) becomes a personal decision made with the patient after the risks and benefits are reviewed. Grade four, five and six are more significantly displaced (4-posterior,5-superior and 6-inferior, under the acromion) all need operative repair. There are many treatments and the method of ligament reconstruction recommended includes 5 key features, a method of repair and reconstruction of the torn ligaments incorporated in my practice over 10 years ago, and they are best depicted on my patient education pages on our website under my tab: http://www.togct.com/downloads/reznik/ AC_Joint_Reconstruction.pdf
Dr. Alan M. Reznik, M.D.
The rotator cuff is made up of four muscles and their tendons. The four muscles originate from the “wing bone” of the shoulder (the scapula) and together form a single tendon unit. This unit inserts on the upper humerus. It primarily helps to stabilize the ball of the shoulder within the joint, rotates the humerus and helps lift the arm. Rotator cuff tears are most common in people over the age of 40 who do repetitive overhead work, sports or weight training. It may also occur in younger patients following acute trauma or sports activity. Tears can be partial or full thickness. Partial tears can be within the tendon itself, on the upper or lower surface. Sometimes these partial tears are associated with calcium deposits; this is called calcific tendonitis.
Patients with rotator cuff tears usually experience loss of motion, weakness and pain. Night pain and pain with certain arm motions are typically the most difficult for a patient with a rotator cuff tear. Loss of sleep often affects daily life and inability to lift common items (like a container of milk) frequently brings the patient to the doctor.
Figure 1: Normal anatomy of the shoulder
Treatment:When a rotator cuff tear is involving more that ½ the thickness of the tendon and/or the patient has failed conservative treatments, surgical repair is often the best option. Dr. Reznik performs this surgery through a fiber-optic scope using small incisions on an out patient basis. The type of repair and recovery depends on the size, shape and location of the tear. A partial tear may require only a trimming or smoothing procedure called a“debridement.”Removing thickened bursal tissues (bursitis) or calcium deposits may also help. When bone spurs are impinging on the tendon they can also be a source of pain and would be removed at the same time. A complete tear within the substance of the tendon is repaired by suturing the two sides of the tendon. If the tendon is torn from its insertion on the tuberosity of the humerus, it can be repaired directly to the bone using tiny suture anchors. The complication rate for arthroscopic repair is extremely low. For example the risk of infection for open surgery is near 1 in 100 were as in arthroscopic surgery it is less than 1 in 2000. Remember, the sutures hold the tendon in place while your body heals, so your post op activities and restrictions will depend on the type of tear you have.
Arthroscopic Repair The cuff is seen through arthroscopic cannula (Figure 1) and then the cuff can be cleared of scar tissue and debris (Figure 2). Once the repair site is ready an anchor is introduced and placed in the bone (Figures 3 and 4). With the suture firmly in the bone (Figure 5) the suture can be passed through the tendon (Figure 6) and tied in place. Pending the size of the tear, repeating these steps multiple times completes the repair (Figure 7).
Figure 1: Cannula placement Lateral shoulder.
Figure 2: Rotator cuff tear with exposed bone edge.
Figure 3: Introducing the Bone anchor.
Figure 4: Placing anchor in bone.
Figure 5: Sutures anchored to the bone.
Figure 6: Suture passing.
Figure 7: The cuff tear is sutured to the bone
General Instructions All Rotator Cuff Repair Patients:
Diet: You may resume a regular diet when you return home. Most patients start with tea or broth adding crackers or toast, then a non-spicy sandwich. If you become nauseated,check to see if one of your medications is upsetting your stomach, most narcotics can. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle it and drink some clear liquids.
Lungs: After surgery you are encouraged to deep breathe and cough frequently (at lease3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the risk of developing a post anesthetic pneumonia.
Pain Control: Take medication as prescribed by Dr Reznik. Please call our office with any questions regarding your medication.
Sling: Patients are to wear the pillow sling at all times for 3 weeks. Move fingers and wrist often. Expect some swelling. Use Ice pack for 20 minutes periods throughout the first 24 hours after surgery and then as needed. It is recommended that patients wear the sling with the pillow removed when going out for the next 3 weeks. .This will help to alert others to avoid the affected arm during this healing period.
Driving: Patients cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12:00 position on the steering wheel and can move hands freely from the 9:00 –3:00 position.
Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours)but should in general wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take an aspirin (unless allergic).
Returning to Work: A patient with a small tear, and/or low demand work, can usually return to work within 3 weeks. They will still have restrictions on lifting and overhead use. Patients with higher demand jobs or repetitive arm use need at least 6 weeks. Any heavy labor with overhead lifting can take at least 4-6 months.
Patients at high risk for blood clots include:
These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.
Vital to your recovery of good shoulder function is a graduated activity and exercise program to increase muscle strength and motion.You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help prevent blood clots.
Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. And, it is very important for you to start therapy when recommended.
To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.
Rotator Cuff Repair Recovery Plan:
Day 1: The Day of Surgery
Maintain dressing and 4x4 bandages if needed for drainage through dressing. Use ice pack for 20 minute periods throughout today. (Do not place ice directly on skin to avoid frostbite.) Keep pillow sling on at all times. Move fingers and wrist often. Expect some swelling, if you have any change in skin color or sensation in arm, notify our office.When sleeping, most patients find sleeping in a semi-upright position is more comfortable for the first few weeks after shoulder surgery. Begin hand squeezing and wrist range of motion exercises tonight. (See exercise list) The arm sling must remain on at all other times, including bedtime.
Day 2: The Day after Surgery Same as Day 1
Day 3: (usually about 48 hours after surgery)Continue same activities, including using ice for 20 minute periods as needed. You should remove your dressing. You may remove the sling to shower today, supporting the affected arm with the opposite hand. You may wash the skin around the incisions. When washing the under arm, do not use a large amount of soap. It may dry out the skin and cause a rash. After a short shower, dry the shoulder well and place Band-aids over incisions. You may begin elbow range of motion exercise today. Physical therapy will start today unless otherwise directed by Dr. Reznik. Add Biceps Curls to your home exercise program.
Change band-aids as daily as needed. Maintain sling use. Continue exercises, adding Wall Walking and Pendulum exercises.
The first Post-op visit: Usually after 7-10 days: Your sutures will be removed at this visit. Further instructions will be given to your rehabilitation and recovery. You may increase your biceps curls by add light weight only if comfortable.
Exercises: Do three times each day as directed
Starting Day 1:
Hand squeezes or grip strengthening: Using a small soft rubber ball or soft sponge,squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.
Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.
On Day 3 add:
Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This will decrease pain and prevent elbow stiffness.
On Day 4 add:
Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day.
Not before Day 7-10 add:
Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk”the fingers of the affected hand up the wall as high as comfort allows. Mark the sot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Do not let the hand drop down from the wall- walk your fingers down as well as up. Dropping the arm will strain the repair and be painful. If having weakness on the way down, feel free to use the other arm to help.
Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. When comfortable try it holding a very small can to start, in a few days you can increase can size only as comfort allows. This exercise should not be painful. If painful decrease or eliminate the weight.
Copyright © 2010, TOG All rights reserved. Revised 4/18/11