The rotator cuff is a combination of 4 tendons around the ball of the humerus that form a cuff of tissue to help the shoulder move. The specific names of the tendons are: subscapularis, supraspinatus, infraspinatus, and teres minor. The subscapularis is the tendon in the front of the shoulder. It helps to rotate the arm towards the body. Although it can tear, it is not as frequent as the other tendons. The supraspinatus is the work-horse tendon. It is the most commonly torn tendon. It is on the top of the shoulder and helps with bringing the arm up and down. The other two tendons, the infraspinatus and teres minor, are located more towards the back of the shoulder. They help with rotating the arm out to the side.
The rotator cuff can tear for many reasons. Sometimes the rotator cuff tears traumatically, as with a fall. Other times, the rotator cuff can tear because of overuse or degeneration. The rotator cuff can be fully torn or even partially torn. The most common symptom of a tear is pain with overhead movements, pain at night, and pain with lifting objects. When the rotator cuff tear is large enough, we can also see limitation of movement. Obviously, there are many more causes to shoulder pain than rotator cuff tears.
Treatment options depend on how long the symptoms have been around, the size of the tear, and any other injuries to the shoulder. Please remember that 20% of the population, over the age of 50, have some sort of rotator cuff pathology, but most do not have pain. Therefore, your surgeon will do a thorough physical examination and review of your studies to determine if you are a surgical candidate. Conservative treatment options include physical therapy, steroid injections, and activity modifications.
Imaging studies help with the diagnosis and treatment of rotator cuff pathology. Most patients come with or have had an MRI, but x-rays are still important to evaluate the bony anatomy and structure of the shoulder. An MRI is the most efficient way of detecting a rotator cuff tear, and it allows us to look at how much has torn, the quality of the tendon, and if any other structures are damaged in the shoulder.
The goal of surgery is to reduce or eliminate pain, and improve function. Whereas most rotator cuff conditions can be treated arthroscopically, certainly not all tears are amenable to arthroscopic techniques. The factors used to decide whether or not this is possible include:
- The size of the tear
- The mobility of the tendon tissue
- The quality of the tendon tissue
- The quality of the bone
Surgery typically is an outpatient procedure. You will receive a general anesthetic, in addition to a nerve block or pain catheter to your operative side. The nerve block and/or catheter is placed by the anesthesia service and allows you to wake up relatively pain-free. When the pain block or catheter starts to wear off, you can start easing into your pain medication.
During surgery, you are positioned into a “beach chair” position, with all of your extremities carefully padded. Your head is also supported in a padded head holder. After performing a “time out”, where we verify the operative site, your arm is cleaned and sterilely draped. We perform the surgery through a couple of small poke-hole incisions around the shoulder. Through these incisions, we are able to visualize the tear and repair it.
The shoulder is thoroughly examined to make sure there are no other issues to address during surgery. The rotator cuff attaches to a bony area on the ball of the shoulder called the greater tuberosity. This area is cleaned and prepared with motorized shavers and burrs to provide a healthy base for the rotator cuff tendon to heal. The rotator cuff is attached to the bone with bone anchors. These anchors are not metal, but have suture attached to them that is sewn into the rotator cuff tendon with small arthroscopic needles. Once the sutures are placed and using proper arthroscopic knot tying techniques, the rotator cuff is tied down to the bone. There are many different configurations of repairs that have been described, but this all depends on your specific type of tear.
Often times after the rotator cuff is repaired, we also clean out any bone spurs on the undersurface of the acromion. This is called a subacromial decompression.
The small incisions around the shoulder are closed and the arm is placed into a sling and pillow device for immobilization. It is very important that you stay in the sling and pillow and adhere to the rehabilitation protocol.
Sometimes we move the shoulder very quickly after the procedure, but other times we keep you in the sling for a couple of weeks prior to even moving the shoulder. This will be explained to you after the procedure and very specific instructions will be given to you and your therapist.
Once your pain is under control, you are eating and keeping food down, and you are medically stable, you can be discharged home. You will get a full set of instructions of Do’s and Don’ts. Basically make sure to keep your incision clean and dry. If you have any questions on what you should be doing or not doing to your shoulder, make sure to ask your surgeon or the nurses/residents. You will be seen in the office for a check up and to remove any staples or sutures in 7 – 10 days after surgery. You will also be given a pain medication prescription. Please take the pain medication as directed. Eat a healthy diet and get plenty of rest. Also remember that ICE is a form of pain relief and you should ice the shoulder regularly.
Typically you are in the sling for 6 weeks after surgery but are coming out of the sling for very prescribed movements that you will be taught. Physical therapy is an important part of the rehabilitation process, but depending on how bad your rotator cuff tear was, your therapy may be delayed so your tendon can heal. Full healing from a rotator cuff repair is approximately 5 – 6 months after the surgery. This timing will be discussed further with you depending on the size of your rotator cuff tear.
We hope this provides a bit more insight into your surgical procedure for rotator cuff repair. As always, if you have any questions, please contact our office at 248-988-8085.