Older patient suffers from sore shoulder

The rotator cuff is a group of four muscles that attach from the scapula or shoulder blade to the humerus or arm bone. Along with the deltoid muscle, which is the large muscle that covers the shoulder, the rotator cuff works to move the shoulder joint.

 

Damage to the rotator cuff is a common source of shoulder pain. Injuries, or degeneration that occurs with overuse or age, can lead to pain. Pain is usually felt about the shoulder or sometimes down the outer aspect of the arm. Use of the arm, especially reaching overhead, often makes the pain worse. Sometimes patients feel that the arm is weak and depending upon the severity of the problem may actually notice new mechanical symptoms such as popping or grinding within the shoulder. If those symptoms of pain restrict the patient’s use of the arm they may develop a secondary condition called adhesive capsulitis or “frozen shoulder” where the joint itself becomes stiff so that even with assistance from the other arm the injured shoulder won’t move.

Sometimes patients sustain a specific injury that causes a rotator cuff tear. Common injuries include strains while trying to lift a heavy object, an unexpected pull on the arm, or a fall onto the arm. Tears can be partial thickness or complete thickness. In partial thickness tears only a percentage of the tendon’s attachment to the bone is pulled away where in complete tears the entire attachment is torn away. Most commonly just one of the four rotator cuff tendons is torn, although tears to 2 or 3 tendons do also occur.

Partial tears that involve less than 50% of the tendon thickness frequently can be managed or treated effectively with a period of rest, a course of anti-inflammatory medication, physical therapy, and possibly a local cortisone injection. Those that injure more than 50% of the tendon thickness frequently cause ongoing pain as do those that are completely torn from the bone. These injuries are more likely to require surgical repair.

Rotator cuff problems can also be secondary to overuse or simple age related degenerative changes (wear and tear). It is estimated that 10% of patients over the age of 60 years will have a rotator cuff tear and that number increases to more than 30% of the patients over 80 years of age. Bone spurs can form as we age and contribute to the development of these tears.

Not all age related rotator cuff tears cause pain but for those that do as well as those that occur in patients from a distinct injury surgery becomes an option. In my practice repair is done with arthroscopic technique. Many surgeons still use a single larger incision or so called “open” technique. Both open and arthroscopic technique can work well. For me and my patients I think that the arthroscopic technique allows for better assessment of the tear in the operating room due to better visualization than can be obtained thru even a large incision, less pain and postoperative stiffness, and better cosmetics.

  • About the Surgery

    Surgical repair typically involves what I describe to patients as planting the tendon back down to the bone from where it was torn away. Most commonly what are referred to as suture anchors are placed into the bone. The sutures attached to these anchors are passed thru the tendon and then tied down to reattach the tendon to the bone. At this point the situation is much like planting a tree and staking it to the ground. The tree will have some stability from the stake but real stability occurs once the tree puts out roots. The same happens with rotator cuff repairs. The tendon has to “root” into the bone to establish a lasting and strong attachment. Just like the tree takes time to establish roots so does the tendon repair. A progressive exercise program will be prescribed in order to protect the repair and give it time to heal back to the bone.

    Typically patients are discharged from the surgical facility on the day of surgery. Surgery requires general anesthesia and typically takes several hours. It is accomplished through a number of small poke holes. Patients will be discharged with pain medication as well as with their arm in a sling. They can remove their bandage and shower on the 3rd day following surgery simply covering their poke hole with Band-Aids from that point on. Typically the few stitches are removed at the first postoperative office visit 4 or 5 days after surgery.

  • Recovery

    Patients begin “pendulum” exercises in the first few days after surgery and are allowed to remove their sling for their pendulum exercises, while bathing, and while sitting in a chair.  They should wear it for the first 6 weeks after surgery when they are up and walking around as well as while sleeping.  Typically the arm can be used for light keyboarding activities within a few days or weeks but should not be used for reaching or pushing up out of chairs for the first 6 weeks.

    Immediately after surgery, most patients are more comfortable sleeping in a reclining chair or propped up on pillows.  Four weeks after surgery patients begin passive elevation of the shoulder.  We will teach you these exercises during your office visit and they are reviewed with diagrams below.  The sling is discontinued 6 weeks after surgery and patients begin to use the arm for reaching and start new stretching exercises.  Strengthening and progressive stretching are begun 8 weeks post operatively.  The process of strengthening the repaired tendon usually goes on for several months and sometimes more.  Most of my patients are referred to a physical therapist 8 weeks following surgery.   Prior to that time most can accomplish the recommended exercises for 5-10 minutes 4-6 times each day without the expense and inconvenience of going to an actual therapy facility.  Full recovery is generally expected between 4 and 6 months following surgical repair.

  • Other Considerations

    All surgeries have some risk. My expectation is that patients will return to normal function following their rotator cuff repair surgery. That being said many factors impact the ultimate outcome. Tears that have been present for longer periods of time before repair are typically associated with a decrease in tendon quality as well as less tendon mobility. Because the tendons are like springs they can pull further away from their normal location as time passes. If the tendons are pulled far away from their normal location, and have been torn for longer periods of time, repair or returning the tendons to their normal positions can be more difficult and even less successful. Large tears that involve 2 or 3 tendons statistically have less successful outcomes than smaller 1 tendon tears. Age and osteoporosis can affect the strength of the bone that the tendon needs to be reattached to. Smoking has been shown to impair healing of tendon repairs.

    Sometimes rotator cuff tears are associated with other problems like biceps tendon tears, bone spurs, or arthritis of the A.C. or acromioclaviclar joint where the collar bone joins the shoulder blade. You can read more about these other problems thru the links below. Be assured that the plan will be to treat these other problems at the time of your rotator cuff repair surgery if I have identified them to you as associated problems.

    I hope that you have found this information helpful as you search for an orthopedic surgeon to care for your rotator cuff problem or as you prepare for your upcoming surgery. In either case I look forward to helping you return to your active life without your current pain.

     

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