Rotator Cuff Injury and Surgery

March 18, 2010

What is the rotator cuff?
The rotator cuff is a set of 4 muscles that motor the shoulder joint. These muscles originate from the shoulder blade (or scapula) and turn into fibrous tendons as they approach the outer aspect of the shoulder. These 4 tendons surround the front, top, and back of the shoulder joint. A lubricating tissue (or bursa) lies on the surface of the rotator cuff tendons. The tendons and bursa normally glide smoothly between the bone at the tip of the shoulder (called the acromion) and the top of the upper arm bone (the humerus.) When the rotator cuff muscles contract, they pull on the rotator cuff tendons, allowing the shoulder to move through the wide range of motion which we enjoy during daily and recreational activities.

How is the rotator cuff injured?
The rotator cuff may be injured by one dramatic trauma, such as falling on an outstretched arm, or it may be injured by repetitive overhand activity. Either form of injury can lead to swelling of the rotator cuff tendon and its bursa known as impingement syndrome. Either injury may also result in a complete tearing of the rotator cuff tendon from the humerus bone, known as a rotator cuff tear.

What is impingement syndrome?
When the rotator cuff tendons and the overlying bursa become swollen and inflamed it produces impingement syndrome. There are many factors that make someone more likely to have impingement. The most common is the size, shape and thickness of the outer edge of the scapula bone (the acromion.) The acromion may have a bony spur on its front edge which points down towards the rotator cuff tendon. With repetitive forward elevation and overhead activity, the rotator cuff and bursa may impact on this spur and become chronically irritated. Repetitive activities which involve forward elevation of the arm may put a patient at higher risk for impingement syndrome.

How is impingement syndrome diagnosed?
Impingement syndrome results in pain with overhead activity such as lifting a coat into a closet, placing items onto a shelf or even throwing a ball. Frequently the pain is worse at night and often interrupts sleep. If a patient has severe impingement pain, they may also develop some weakness in the arm but they most often are able to lift the arm overhead. Impingement syndrome is best diagnosed by a physical examination by the orthopedist. Special impingement tests can suggest impingement syndrome. Plain X-rays of the shoulder may show the presence of a bony spur; an MRI (magnetic resonance imaging) may be obtained to further identify inflammation of the bursa and the rotator cuff, and to rule out a full tear of the rotator cuff.

How is impingement syndrome treated? What view is this?
Treatment begins with a period of rest from overhead activity, ice, anti-inflammatory medications (such as Motrin or Advil) and an exercise program. The exercise program may be self-directed or done with a physical therapist. Often a cortisone injection into the bursal space above the rotator cuff tendon is helpful to relieve swelling, inflammation and night pain.

Is surgery necessary for impingement syndrome?

The arrows indicate the spur before removalAfter removal
If impingement symptoms continue in spite of the above steps and the patient is unable to carry out his or her work, recreational activities, and daily chores, and has difficulty with sleeping, then surgery is warranted. An arthroscope can be used to treat impingement syndrome. The arthroscope is introduced into the shoulder joint and visualizes the surfaces of the bones, the shoulder ligaments and the undersurface of the rotator cuff. The arthroscope allows confirmation that the rotator cuff is intact and, if this is the case, the arthroscope can then be introduced into the bursal space just above the rotator cuff. With the aid of a small arthroscopic shaver, the chronically thickened, inflamed bursa can be removed; with the use of a burr any bone spurs can be removed to allow the rotator cuff to glide smoothly and freely through the bursal space without impinging on the undersurface of the acromion bone. This procedure takes about 60 minutes and is done on an outpatient basis (without an overnight stay in the hospital.)

How is the shoulder cared for after arthroscopy?
A bulky dressing is applied to the shoulder area and a sling is provided for support of the arm. The patient is encouraged to wean himself or herself from the sling within the first 24 hours and to use the arm for non-vigorous activities. The dressing is removed after 48 hours. Some bruising and swelling may be present. The patient will see 2-3 small incisions, each with a stitch. Patients return for a follow up visit in 7-10 days and the stitches are removed at that time. An exercise program with a physical therapist is often started to help gain full range of motion and restore strength to the rotator cuff.

How long is the recovery after shoulder arthroscopy?
Patients may return to work within several days, but if their job requires heavy lifting or climbing return may be delayed several weeks. Full recovery and return to pre-injury athletic activities occurs in 8-12 weeks after shoulder arthroscopy.

What is a rotator cuff tear?
The rotator cuff tendons can be torn with a fall on the outstretched arm which causes the rotator cuff to be pinched between the upper arm bone (humerus) and the shoulder blade (acromion). The rotator cuff can also be torn by chronic impingement of the tendon on an acromial spur. The spur progressively breaks down the rotator cuff and may finally lead to a full thickness tear.

How is a rotator cuff tear diagnosed?

Normal Torn

Patients with a rotator cuff tear often show symptoms similar to chronic impingement (pain with overhead activity and night pain.) However, patients with a rotator cuff tear often have significant weakness in their arm and may be completely unable to lift their arm away from their side. A rotator cuff tear is best diagnosed by a physical examination by an orthopedist. An MRI (magnetic resonance imaging) may be obtained to confirm a full thickness rotator cuff tear.

How is a rotator cuff tear treated?
A full thickness rotator cuff tear often results in significant disability in the arm. If the pain and weakness seriously interfere with work, recreational activities and sleep patterns, then surgery is necessary. The rotator cuff tear does not heal on its own. An arthroscope is used to view the shoulder joint and document any injury to the surfaces of the shoulder bones and also to confirm the presence, size and position of the rotator cuff tear. The arthroscope may also be used to remove any bone spurs which are present in the shoulder area. Current techniques for repair of a rotator cuff tear require approximately a 2 inch incision over the outer aspect of the shoulder. Through this incision the rotator cuff tear is identified and the torn edge is reattached to the humerus bone with stitches. This procedure takes about 1½-2 hours and may be done on an outpatient basis (without an overnight stay in the hospital.)

How is the shoulder cared for after rotator cuff repair?
A sterile dressing is applied to the shoulder joint and the arm is placed in a shoulder immobilizer (a sling with a strap that extends around the waist). Patients are encouraged to use their hand, wrist, and elbow but active elevation of the arm away from the body is not allowed. The dressing is removed 48 hours later. Some bruising and swelling may be present. The patient will see a 2 inch incision and 1 or 2 arthroscopy incisions. The patient returns for a follow-up visit in 7-10 days and the stitches are removed. A formal exercise program is then started with a physical therapist.

How long is the recovery period after rotator cuff repair?
It requires approximately 4-6 weeks for the rotator cuff tendon to heal down into the bone. During that time if active motion of the shoulder is carried out, the rotator cuff may be pulled away from its repair site. Patients begin a formal physical therapy program at approximately 10-14 days from surgery. For the first 4-6 weeks, patients are allowed to actively move their hand, wrist and elbow. Shoulder motion, however, is purely passive during that initial period. This passive motion is carried out by the physical therapist or by the patient with the assistance of the opposite arm. At 4-6 weeks the rotator cuff tendon has healed enough to the bone that active assisted and active range of motion may be started. Strengthening of the rotator cuff muscles begins at about 8 weeks from surgery and continues for 2-3 months.

Patients may return to work within several days, but if their job requires heavy lifting or climbing return may be delayed for several months. Full recovery and return to pre-injury athletic activity occurs within 3-6 months from rotator cuff repair.