By Ron Romanelli, M.D.
We all take for granted the complicated mechanics that allow our bodies to literally and figuratively move through our daily tasks. Only when we stop and reflect on this, do we realize the true complexity of our musculoskeletal system. Specifically, our shoulders enable us to perform various jobs, often not fully appreciated until an injury occurs. One of the most common injuries we see and treat at OCI is a rotator cuff tear.
The shoulder has a wider range of motion than any other joint in the body. This joint consists of an “O” ring around the shoulder socket, as well as a capsule and surrounding rotator cuff muscles. The rotator cuff is a group of four muscles and their corresponding tendons that wrap around the front, back and top of the shoulder joint.
The most common symptom of a rotator cuff problem is weakness or pain. Usually, it is described as general discomfort and is exacerbated with certain movements of the shoulder. Like many orthopedic conditions, the mechanics of rotator cuff problems can be separated into repetitive use injuries and traumatic injuries. Over time, repetitive use of the shoulder may wear out the tendon, and a rotator cuff tear can develop. Traumatic injuries, such as falling on an outstretched arm, can also cause rotator cuff tears.
As we age, overuse of our shoulders can cause several different issues, including tendinitis, impingement and rotator cuff tears. When tendons in the joint become irritated or damaged, we call it tendonitis. Impingement occurs when the fixed acromion bone on the top of the shoulder constantly rubs the rotator cuff resulting in shoulder aches and pains. Impingement syndrome can also develop into a rotator cuff tear.
A rotator cuff tear is diagnosed by listening to the patient’s history and completing a physical exam, as well as X-rays and an MRI. Typically, when evaluating patients, MRI scans are utilized not only to assess the size of the tear, but also assess the anatomy of the rotator cuff. Initially, we treat the problem with conservative management using medications, exercises and physical therapy with occasional cortisone injections. If conservative measures fail, surgical procedures for this problem become necessary. The most common reason for surgery is persistence of pain despite injections. When pain persists or weakness prevails, arthroscopic surgical techniques can typically give reliable pain-relieving outcomes.
Traditionally, surgeons used an open surgical technique to access the injury which involved a larger incision and splitting of the muscle. Now, most cases of shoulder surgery are treated with arthroscopy. Some time ago, our surgeons made the transition from open rotator cuff repair to arthroscopic rotator cuff repair after countless hours studying and refining techniques to provide the best leading-edge care to our patients. Not only can small repairs be done this way, but large rotator cuff repairs can be performed safely and effectively with excellent results.
The word arthroscopy comes from two Greek words: “arthro” (joint) and “skopein” (to look). It is a minimally invasive procedure which entails small incisions and small tubes called cannulas. During arthroscopic repair, the surgeon inserts a small camera called an arthroscope into the shoulder joint through the cannulas. The camera displays pictures on a video screen. These images are viewed to guide miniature surgical instruments and arthroscopic repair techniques. Arthroscopy allows us to diagnose the problem because we can see inside the joint, as well as examine the type of rotator cuff tear that is present, which enables us to deliver a more accurate surgical repair.
The current standard for arthroscopic repair involves special instruments that pass through the torn rotator cuff tissue, through the tendon and are anchored to the bone with sutures and knots. Another technique involves knotless sutures that tension the cuff to the bone. Both of these approaches avoid cutting muscles to access the damage, therefore requiring less pain and smaller cosmetic scars.
Arthroscopic surgery is performed on an outpatient basis using a light general anesthetic, as well as local anesthesia for patient comfort. Our surgeons at OCI also perform a shoulder block, or anesthetizing/numbing of the shoulder, so the patient does not have pain when they wake from the operation. OCI patients have excellent pain management results due in part to the anesthesia and shoulder block, in conjunction with a multi-modality utilization of medications. This means patients receive anti-inflammatory medications preoperatively, anti-nausea medications, and minimal narcotic medications, resulting in minimal pain postoperatively.
Advances in Arthroscopy
Through the years, arthroscopic surgery has been refined due to advances in technology which have created multiple ways to approach repair of rotator cuff tears. Companies have improved fixation methods, as well as the techniques to assist surgeons to give their patients the best outcomes. Current research is focused on sutures with growth factors and/or injectable agents to help with healing in difficult rotator cuff repairs.
We now have multiple options for bone anchors with sutures that are single loaded, double loaded, or triple loaded. Surgeons typically perform sliding knots and non-sliding knots in order to repair rotator cuff tears, but there are also knotless techniques. We select our tools and techniques specifically for each patient and their unique injury. Techniques include a single row or double row repair or a transosseous-equivalent repair. Special anchors allow us to not only suture the muscle down to the bony footprint of the rotator cuff, but also allows us to place sutures on the side, which is a double reinforcing type of repair. All of these options mean there is no one way to correct a rotator cuff injury.
We utilize early physical therapy to assure patients achieve their best outcomes. Tendon healing typically takes six weeks, during which
time we perform gentle, passive motion on the shoulder. The second phase is a strengthening program, typically from six to 12 weeks. It generally takes at least six months to a year to reach maximum medical improvement for the majority of rotator cuff tears. The patient, doctor and therapist work together as a team to achieve excellent results and eliminate pain and suffering related to rotator cuff problems.
Arthroscopic results are good to excellent for 95% of small tears, but as the tear progresses to a large size tear, the success rate decreases. Success is dependent on the age of the patient, the size of the tear, and the length of time the tear has been present. Often times, early evaluation and treatment are necessary for good results.
Neglecting a rotator cuff tear not only means declining surgical success rates, but patients experience arthropathy, an imbalance of the shoulder which can lead to secondary arthritis. This end-stage problem of a rotator cuff tear that is not fixed may lead to a need for a reverse shoulder replacement. Putting off treatment will only result in prolonging the discomfort, and over time, can create more damage. If you have shoulder pain, please contact us to set up an appointment with one of our talented surgeons to begin the diagnostic and, if necessary, treatment process.
This article was published in the July-September 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.