Surgery performed in Seattle
The Rotator Cuff is a group of four muscles and tendons that surround the humeral head (ball) and glenoid (shoulder socket). The muscles attach to the humeral head by way of the tendons. The role of the rotator cuff is to stabilize the humeral head on the glenoid and hold it down while the arm is elevated. If the humeral head isn’t stabilized, it rides up on the glenoid and impinges on the acromion, which sits above the rotator cuff. Tears of the rotator cuff often occur at their attachment to bone. Injuries of the rotator cuff range from Impingement Syndrome to Rotator Cuff Tears.
Impingement syndrom is tendinitis and bursitis of the rotator cuff and is most common in patients in their 30’s and 40’s. It is usually due to repetitive overhead activities such as throwing a baseball, hitting a volleyball, playing tennis, painting or hammering, and swimming. This causes pain over the outside and back part of the shoulder that increases with bringing the arm out to the side. This pain usually radiates down the outer part of the arm.
Normal Rotator Cuff as seen from the back of the shoulder
Treatment of impingement syndrome includes a course of physical therapy, rest, ice and anti-inflammatory medications. If this is not successful, a cortisone injection into the bursa, a fluid filled sac above the rotator cuff, may help. Nonoperative treatment is usually successful. For refractory cases, arthroscopic acromioplasty or subacromial decompression is performed where the bursa and prominent undersurface of the acromion are removed. This has an 85% success rate.
Rotator Cuff tears
Rotator Cuff tears may be partial thickness (tear does not extend all the way through the tendon) or full thickness. There is also variability in the type and size of tears.
Undersurface of the Acromion as seen from the back of the shoulder
Undersurface of the acromion following acromioplasty (shaving the acromion)
Signs and Symptoms of a Rotator Cuff Tear
Rotator Cuff tears usually cause pain on the back and top of the shoulder and may be associated with clicking or catching. Overhead activity such as throwing, lifting weights or swimming can aggravate these symptoms. The onset of the symptoms may be gradual or it may occur during a single event such as a fall on the shoulder. Examination of the shoulder may reveal tenderness over the rotator cuff attachment site, pain with elevation and/or internal rotation of the shoulder, or pain and weakness with rotator cuff resistance.
Diagnosis of Rotator Cuff Injuries
Although the signs and symptoms may lead to a probable diagnosis, there is not one single exam finding or group of symptoms that are conclusive for a Rotator Cuff tear. Many of these findings overlap with other shoulder problems. X-rays and an MRI combined with an arthrogram (injection of dye into the shoulder joint) are recommended to confirm the diagnosis and rule out other conditions.
Rotator Cuff Tear (short white arrow)
Rotator Cuff Repair
Treatment of Rotator Cuff Tears
Many Rotator Cuff tears may be treated nonoperatively with relative rest and physical therapy, especially partial thickness tears. Icing the shoulder and anti-inflammatory medications can help with pain. If rehabilitation is not successful, or for cases where there has been a traumatic event, surgical treatment may be considered. The indications for surgery should be based on individual circumstances such as type of tear, patient age, activity level, functional needs, response to previous treatment, and time in season for athletes. Surgery consists of repair of the rotator cuff if it is a full thickness tear or debridement (shaving) if it is a partial thickness tear that involves less than 50% of the tendon thickness.
Repair involves creating bleeding of the bone on the greater tuberosity of the humeral head where the tendon tears away from the bone and placing suture anchors in the bone to repair the rotator cuff down to it.
Debridement involves shaving the frayed edges of a partial tear and can be done if the tear is a mild to moderate partial tear.
There are three ways a rotator cuff is repaired:
1) Open - using a large incision and taking the deltoid muscle attachment off the acromion and later repairing it back to the bone
2) Mini-Open – using arthroscopy to shave the acromion (acromioplasty) and evaluate the remainder of the shoulder joint. The rotator cuff tear is then repaired through a smaller incision than with the open approach and the deltoid muscle is split rather than taken off the bone.
3) Arthroscopic – using multiple small incisions to repair the rotator cuff tear and to perform the acromioplasty and other procedures such as biceps or labral surgery.
My preference is Arthroscopic Rotator Cuff Repair. Arthroscopy uses small incisions allowing the surgeon to view the entire shoulder joint on a TV monitor and use small instruments to perform the surgery. It also results in less pain and easier rehabilitation than open surgery that utilizes large incisions. The surgery is done as an outpatient procedure allowing patients to go home the same day.
Rotator Cuff Tear as seen from inside the shoulder joint
Rotator Cuff Tear as seen from above the tendon (subacromial space)
Rotator Cuff Tear and greater tuberosity (attachment site) prepared for repair
Repaired Rotator Cuff tear
Repaired Rotator Cuff as seen from inside the shoulder joint
Rehabilitation of Rotator Cuff Tears
Rotator Cuff Repair
The rehabilitation following a Rotator Cuff Repair is much different than a debridement. If a repair is done, patients are placed in a shoulder immobilizer with a small pillow next to the side to protect the repair for approximately 6 weeks. Physical therapy is started 1 week after surgery and involves passive range of motion where the therapist moves the shoulder within a specified range. Active motion where the patient starts moving the shoulder without assistance begins at 6 weeks after surgery. There is a progression to more aggressive strengthening at 3-4 months after surgery and return to some sports and activities at 4-6 months after surgery or longer. It takes most people 6 -12 months to fully rehabilitate their shoulder after rotator cuff repair. It may take longer for those with chronic or massive tears. Other factors such as age, general health, and use of tobacco products also influence healing. Return to pitching may take 12 months and swimming 8-10 months after surgery. It is important to recognize that return to sport is based on multiple factors including biologic healing, age, return of strength and endurance, subjective improvement, and a gradual/incremental return to sport specific activities. Therefore, return to sport timeframes vary.
Rotator Cuff Debridement
If a debridement or shaving is done, patients are placed in a sling for several days to a week. Physical therapy begins approximately 1 week after surgery. Range of motion is allowed as tolerated and strengthening is started 1-2 weeks after surgery. Return to sports or full activity is allowed when pain improves and full range of motion and strength return. This may be as soon as 2-3 months after surgery for some sports or activities.
Dr. Khalfayan’s Tip: Sleeping is difficult after surgery. It’s helpful to sleep in a semi-reclining position propping yourself up on pillows behind your head, neck, and upper back or in a recliner until you are comfortable sleeping flat in bed.