The rotator cuff is the complex of tendons and muscles that provide stability to the shoulder, with the three largest muscles being the supraspinatus, the infraspinatus, and the subscapularis. A rotator cuff tear may occur as a result of a single traumatic event or, more commonly, repetitive microtrauma in any of the tendons that connect with these three muscles.
“While these tears can occur from a single traumatic event, they are more commonly seen in patients due to repetitive wear and tear activities that strain and cause the tendon to fail over time,” says Joshua Dines, M.D., orthopaedic surgeon at Hospital for Special Surgery (HSS) in New York. “In athletes and non-athletes alike, the diagnosis of rotator cuff pathology is made by a physical exam and confirmed with an MRI or ultrasound, with MRI being more commonly used.
“In contrast, acute traumatic tears particularly after dislocations are best treated by early operative repair in younger patients,” said Russell F. Warren, M.D., attending orthopedic surgeon at Hospital for Special Surgery and team physician for the New York Giants.
“In most cases,” said Dr. Dines, “a trial of conservative treatment is warranted. This involves stretching and strengthening the rotator cuff muscles as well as the muscles that stabilize the scapula (or shoulder blade). Oftentimes, by strengthening the other muscles in and around the shoulder, one can compensate for a small tear in one of the rotator cuff tendons. When non-operative management fails, surgery can be considered.”
In the past, surgical repair of a torn rotator cuff would be performed through an open or mini-open approach that requires a 1.5 to 4 cm incision, with a slow recovery period and considerable post-operative pain. Now patients have the option of arthroscopic repair – essentially the same procedure but with a minimally invasive technique – that makes a dramatic difference in comfort and produces excellent results.
“As in the knee, use of arthroscopy in the shoulder started with diagnostic evaluation and has progressed to include therapeutic applications,” says Dr. Warren.
During arthroscopic shoulder surgery, the orthopedic surgeon makes small incisions or portals in the affected joint, and then inserts a tiny camera and fiber optics to light the interior space. Pictures obtained with the camera are then projected onto a screen in the operating suite.
Rotator cuff surgery often involves a number of steps, including the removal of any loose tissue fragments in the area. Additionally, the acromion (the upper portion of the scapula) may require smoothing or a portion of the bones forming the acromio-clavicular (AC) joint may need to be removed. If it is inflamed, a bursa (a fluid-filled sac that provides cushioning in the joint) may also be removed (i.e., bursectomy). Finally, the portion of the tendon that has torn is sutured and anchored to the humerus (upper arm bone). If the cuff is badly damaged, the patient may require rotator cuff reconstruction with a tendon obtained from elsewhere in the body.
Over the last decade, arthroscopic surgeries have increased in accessibility and popularity. Dr. Warren, for example, now performs up to 95% of rotator cuff repairs arthroscopically.
“Surgical techniques have considerably improved, such that most rotator cuff tears can be treated and successfully repaired arthroscopically with a minimally invasive approach,” said Dr. Dines. “Rehabilitation exercises, however, are of tantamount importance to the surgery itself and play a critical role in the short-term recovery and long-term health of the shoulder.”
Because patients may feel well quickly, it's particularly important that they exercise care in protecting the joint during the healing period. Shoulder surgeons prescribe a very specific and detailed rehabilitation program following surgery which must be strictly followed. Generally this includes wearing a sling for the first four to six weeks, and participating in a physical therapy program that begins one week after surgery and typically lasts for three to four months. Strengthening exercises begin after the 6 to 10 week healing period; after 12 weeks the patient may return to most activities, but participation in vigorous sports may be restricted for four to six months.
Early physical therapy is not of much value, it usually starts later. The patient is in the sling for approximately four to six weeks. Physical therapy emphasizes range of motion over the next six weeks. Light strength work over the third week emphasizes power development. Most sports will require a four to five month return.