The rotator cuff consists of four muscle-tendon units deep in the shoulder. They are the subscapularis, supraspinatus, infraspinatus and teres minor tendons. Injuries to the rotator cuff, occasionally known as the rotocuff, occur with repetitive overuse or trauma. The degenerative affect of aging is also a large factor.
The rotator cuff tendons and surrounding bursa become stressed causing tendonitis and bursitis, which used to be called impingement, however Orthopaedic surgeons now believe that it is not from pinching of the cuff tendons under the acromion, but resultant from degeneration of the tendon. A tear results when the already weakened tendons are further stressed by activity or impact, such as that which is experienced in the constant grinding of an “overhead sports athlete,” or an who sustains a severe injury, such as a person over 40 years old who dislocates their shoulder. Damage to the Rotator Cuff usually results in chronic pain, weakness, shoulder tenderness, and sleeplessness from night pain.
Most non traumatic rotator cuff injuries can be approached non-surgically. They may be treated with anti-inflammatory medication, nutritional supplements, and a course of shoulder exercises with a Thera-Band®, which is a latex resistive exercise band designed to designed to strengthen the shoulder by providing both positive and negative force on the muscles, as well as improve range of motion and cooperation of muscle groups. Thera-Band® exercises help strengthen the shoulder in Flexion, Abduction, Internal rotation and External rotation. They also help stretch the shoulder into internal rotation, as well as strengthen the Scapula Rotators – namely the lower trapezious, rhomboids, and serratus anterior, which are key muscles to help the scapula rotate out of the “impingement”zone. Three sets of 12 repetitions of each exercise are necessary each day.
Activity modifications are also necessary. Patients need to keep the arm out in front of them and keep the elbow beneath the shoulder level.
In some cases, pain persists and in years past we would inject injection cortisone into the shoulder. In the previous few years we have learned that while one or two cortisone injections into the shoulder may be relatively harmless, repeated injections will accelerated the degeneration of the tendon. Toradol®, and injectable anti-inflamatory has been shown to lead to results that are better than cortisone injection and it doesn’t carry the likelihood in tendon degeneration. Platelet Rich Plasma (PRP) injections, although fashionable, expensive, and not covered by third party medical insurance, has not been shown to be particularly effective, especially when its cost (greater than 50 times more expensive than an injection of Toradol®) is considered.
For patients with history of severe trauma or profound weakness, these treatments will not be successful. In these patients, imaging studies such as MRIs, or arthrograms, may be necessary. And consideration of arthroscopic shoulder surgery for rotator cuff repair is given. Arthroscopic surgery is used to remove the bursa, smooth the undersurface of the acromion if a spur has developed, and guide a suture repair of the tendon back to its home at the greater tuberosity. Arthritis of the Acromioclavicular joint and other shoulder pathology may be addressed at the same time.
Since the attachment of the rotator cuff tendon to the greater tuberosity of the humerus is one of the most difficult areas in the body to heal, especially when the tear is a large or neglected one, we have abandoned early motion and maintain our patients in a sling for eight weeks. Additionally, we utilize a myriad of nutritional supplements, and counsel our patient to completely avoid tobacco and tobacco products.
Out of town patients should plan a two-day stay for this procedure. The post-operative plan is further discussed in our web page regarding arthroscopic and open shoulder surgery.