Rotator cuff tears in the Shoulder
The rotator cuff is synonymous with the shoulder. Talk to anyone that has had shoulder pain and they will know the term “rotator cuff”. Now they may call it something slightly different like Rotor Cup; but they still know it is located in the shoulder and if there is a problem with it, the shoulder hurts. While not all problems with the rotator cuff involve tears, there are times when a tear is high on the list. As we age the likelihood of having a rotator cuff tear goes up.
Generally speaking the rotator cuff is a group of four muscles and their respective tendons. The four tendons surround the humeral head or the “ball” part of the shoulders ball and socket joint. The rotator cuff tendons act like tent ropes. When each one has the appropriate amount of tension on it, the system works well. If one of the tendons loses tension because of injury or irritation the system collapses just like that side of the tent or canopy would collapse. The most commonly injured or effected rotator cuff tendon is the Supraspinatus tendon. This is the tendon on the top of the shoulder that goes under the boney ridge known as the acromion process. It is also the main tent rope, responsible for lifting the arm over head.
Under the age of 30 it takes a significant force or injury to cause a tear of the rotator cuff. Between the ages of 40 and 60 the supraspinatus portion of the rotator cuff is the most likely tendon to tear. It will usually tear as the result of a fall or trauma. On occasion it will tear secondary to thinning caused by inactivity and smoking. As the tendon degenerates it becomes thinner and more susceptible to tearing from a trivial event such as rolling over in bed or performing a quick movement like flipping a bed sheet while making the bed. After the age of 60 the supraspinatus tendon is still the most common tendon to tear either through trivial movement or trauma. The other rotator cuff tendon that will show an increased prevalence of tearing is the subscapularis tendon. This is the rotator cuff tendon in the front of the shoulder.
The supraspinatus and subscapularis tendons actually join in the front of the shoulder and connect to the biceps tendon. If a patient over the age of 60 has a fall that results in a complex tear of both the supraspinatus and subscapularis tendons the biceps tendon will become unstable and start popping and snapping.
According to the American Academy of Orthopedic Surgeons there are several different methods that can be used to repair these types of tears. One key to repair is having the injury properly evaluated earlier than 6-months from the time of the injury. Patient’s that typically wait longer than 6-months see the chances of a favorable recovery go down. The majority of rotator cuff repairs are performed arthroscopically. This is the least invasive type of surgery leaving 3-5 small incisions and a minimum of scarring. When the tears are larger it is not uncommon for the surgeon to use a “mini-open” approach. This is a combination of an arthroscopic surgery and a small incision. This gives the surgeon better visibility of the repair, but will leave a slightly larger scar.
After the surgery your shoulder will be immobilized for ~4-6 weeks to protect the repair. Physical therapy will most commonly start 7-14 days after the operation. You will remove the immobilizer during physical therapy, your home exercise program and for bathing during the early stages of recovery. Depending on the size of the repair the total course of immobilization can be anywhere from 6-11 weeks. Patients always need to remember that just because the outward incisions are healed doesn’t mean the internal repair is completely healed. This can take 6-12 months.
Most rotator cuff repairs require 4-8 months of supervised physical therapy. If the patient waited longer than 6-months to get the tear repaired, the shoulder may stiffen and this will extend the length of physical therapy. Regaining range of motion from a stiff shoulder after a rotator cuff repair can be a tricky task. Mobilization is needed to resolve the stiffness, but the repair needs to be protected at the same time. More times than not a slower approach works best, but can be frustrating for the patient.
The most efficient way to handle an injury is too have it looked at sooner rather than later. Delaying a good assessment will only delay appropriate treatment and lengthen the recovery. Know that while the recovery for a rotator cuff repair can be lengthy, following the advice and direction of the surgeon and rehabilitation specialist will ultimately lead to the most functional post-operative outcome.
Dr. Buchberger is a licensed chiropractor, physical therapist, certified strength and conditioning specialist and Diplomate of the American Chiropractic Board of Sports Physicians with 32 years of clinical sports injury experience. Dr. Buchberger can be contacted at 315-515-3117, www.activeptsolutions.com or www.shouldermadesimple.com