Rotator Cuff Tear

Our Dr. Laith Farjo explains more below about rotator cuff tears of the shoulder.

What is a rotator cuff tear?

There are four (4) muscles that surround your shoulder; they are deep and you cannot feel them. A rotator cuff tear occurs when one of these muscles tears, usually the one on top called the supraspinatus.

How does a rotator cuff tear occur?

There are two kinds of rotator cuff tears. Acute tears happen when a person experiences a sudden injury, such as falling down onto an outstretched arm, or lifting something very heavy with a jerking motion. However, we see Chronic tears much more often. This means that the tear occurs slowly over time, much like a hole slowly gets worn in a sock after years of wear. There is a lot of debate amongst shoulder surgeons about exactly why this happens. We generally agree that there are two important factors:

• There is a relatively poor blood supply to the rotator cuff, especially the supraspinatus. Without a good blood supply, the muscle has a hard time healing itself.
• A spur on the undersurface of the acromion can wear a hole in the rotator cuff, much like a pebble in your shoe will cause a blister on your foot. See the section on impingement syndrome.

What are the symptoms of a rotator cuff tear?

Weakness is a very common symptom, especially difficulty lifting the shoulder overhead. Pain is also a frequent symptom; often patients complain of pain while sleeping on the affected shoulder.

How are these tears diagnosed?

Your doctor will perform a physical examination; often this is all that is needed to diagnose the cuff tears in the hands of a physician who has a lot of experience with them. Usually, x-rays will be ordered to look for a bone spur on the undersurface of the acromion. Sometimes an MRI is ordered. This is very controversial among orthopaedic surgeons currently because MRIs are very expensive (often $800-$1400 depending on the type) and often unnecessary, as the rotator cuff tear can usually be diagnosed by a simple physical examination. Personally, I will base the need for MRI on a case-by-case basis, depending on whether I have particular concerns that only an MRI can address, such as telling me the exact size of the tear and if there is any other problems within the shoulder besides the rotator cuff. In the past, doctors used to order lots of arthrograms, which are plain x-rays taken after a dye has been injected into the shoulder. I do not believe that these give any more information than an MRI, hence I do not order them. An MRI arthrogram — an MRI after a special dye has been injected into the shoulder — sometimes is necessary and provides us with useful information.

What is done to treat rotator cuff tears?

It depends whether the tear is acute or chronic. Acute tears, in a relatively active individual, usually need surgery (see below). Chronic tears are typically treated conservatively first. Conservative treatment usually includes a combination of medicines, physical therapy to strengthen the rotator cuff, and sometimes steroid injections around the rotator cuff to decrease pain and inflammation.

When is it determined that surgery is necessary?

When it becomes evident that conservative therapy is not going to work for a particular patient. There are no set rules for this. This requires a good relationship with your surgeon so that you can come to this conclusion together. Factors that go into this decision include your activity level, age, size of your cuff tear, time that you have had the cuff tear, how long you have been trying conservative therapy, and your general medical health.

What kind of surgery can be done to fix a rotator cuff tear?

There are three types of surgery:

• Open rotator cuff surgery: Using an incision on the front of the shoulder, about five (5) inches long, the rotator cuff is repaired, and the bone spur on the undersurface of the acromion is removed. The cuff is attached back down to the humurus using sutures and holes drilled into the bone.
• Mini-open repair: Using a smaller incision, about two (2) inches, the rotator cuff is repaired. This is usually performed with an arthroscopic removal of the spur (see the video on arthroscopic subacromial decompression). Either bone holes or anchors are used.
• Arthroscopic rotator cuff repair: This type of repair is done completely arthroscopically with several small incisions (0.25 to 0.5 inch). Usually bone anchors are placed into the humerus and used to help attach the cuff with sutures back down to the humerus, where it belongs. These anchors are very small but strong and are made of either metal, plastic, or a special material that is absorbed by your body over time ("bioabsorbable"). This type of rotator cuff tear is the most difficult for a surgeon to perform. Because of this, typically your surgeon cannot guarantee that the repair will be performed all arthroscopically. For example, large tears are sometimes difficult to fix arthroscopically and usually need a mini-open approach. In my practice, however, I am able to repair approximately virtually all rotator cuff tears arthroscopically.

Which type of repair do I prefer?

Because I have had significant experience with arthroscopic cuff repairs, I prefer to try to fix every patient's tear arthroscopically. The pain after surgery is much less, and generally patients go home the day of surgery and do not need to spend a night in the hospital. Recovery is usually faster, and return to work sooner with arthroscopic repairs.

Most orthopaedic surgeons do not perform arthroscopic rotator cuff repairs. This is mostly because they are very hard to do and require special training. Some surgeons criticize arthroscopic repairs because they feel that they are not as strong as mini-open or open repairs. Personally, I feel that a well trained arthroscopic surgeon can repair these tears very well and securely with an all-arthroscopic technique. These techniques are currently the subject of much research and are changing dramatically as time goes by. My philosophy is that the "proof is in the pudding"; my patients seem to do very well with arthroscopic repairs, and are much happier that they did not require large incisions.

Recent research studies have shown that arthroscopic repairs have a lower incidence of postoperative stiffness and overall faster return of function.

Why was my surgeon unable to fix my cuff tear?

A small minority of tears are so big that usual methods to fix them are impossible. These tears typically occur in older people, who have had the tears for long periods of time. Usually just trimming the edges of the tear and removing the acromial bone spur helps to relieve pain (but weakness still persists). Sometimes, uncommon procedures such as tendon transfers and joint replacements are performed for these very large tears. These are decided on a patient by patient basis.

My surgeon said I had a "partial thickness" tear. What is that?

Some tears do not go all the way through the rotator cuff; these are called partial thickness tears. Think back to that pebble in your shoe, before it wears a hole all the way through your sock it first thins the sock, and then slowly over time this turns into a hole. Partial thickness tears less than 50% of the thickness of the entire cuff usually do not need to be repaired. Tears thicker than 50% are usually repaired.

What happens after surgery?

Your arm is placed in a sling. You will usually require this for several weeks. The idea is that we want the cuff to heal back down to the bone (you can't count on the sutures holding it there forever) and therefore do not want you to actively use your arm. However, if you don't move your arm after surgery, then it will get stiff. Our solution to this dilemma is called passive motion: various exercises you will be taught to perform that use your good arm to move the arm that just had surgery. This way, the arm does not get stiff, but we do not stress the repair because you are not using the rotator cuff muscles of the shoulder that just had surgery to move it. I prefer to start these passive exercises one (1) to two (2) days after surgery. Physical therapy is prescribed for most patients. However, I encourage all patients to work on a home exercise program as well. In my experience, those patients who do their exercises very often (once a day, at least), are more likely to have the best results from surgery.

A typical timeline for healing of most tears includes:

• Pain pump and dressings removed after two days.
• Sling for 4 weeks. During this time period, you will be able to use your hand (for example, for cooking, working directly in front of you) almost immediately. Many patients who have significant tears tell me that their use of their arm during this time period is little different than what they were able to do before surgery.
• Home exercises start the day after surgery. Physical therapy begins typically 1-2 weeks after surgery (sometimes sooner).
• After 4 weeks, you can start using your arm out of the sling, but will still have some difficulty/pain raising it over your head.
• After 6 weeks, your arm is regaining strength for overhead use, but still weak.
• Most patients finish physical therapy by about 10-14 weeks after surgery. At this point, most patients feel much better than they did before surgery.
• Patients may experience continued improvements in strength and function for 6 months to a year after the surgery.

Please keep in mind that this describes an average recovery for Dr. Farjo's surgeries only. If you are elderly, have a very large tear, have a lot of stiffness or severe pain before surgery, or other major medical problems, your recovery may take longer.

How painful is this surgery?

Dr. Farjo has always been at the forefront of minimizing pain after shoulder surgery. We use a multi-faceted approach to treat pain, often before it happens. This includes the use of special anti-inflammatory medications immediately before and after surgery, nerve blocks, local anesthesia in addition to general anesthesia, the use of anesthesia providers who are extremely skilled and experienced in the management of shoulder surgery, the use of a pain pump for two days afterwards, and narcotic medications. Everyone's response to pain is different. Typically 25% of my patients report taking virtually no narcotics at all. 50% will take narcotics for a few days, up to one week. And 25% will require narcotics for several weeks. We treat every patient individually and do our best to minimize pain while encouraging transition off narcotics to less addictive medications with fewer side-effects (such as Tylenol or non-steroidal anti-inflammatory medications) as soon as possible.