Shoulder - Rotator Cuff Arthropathy
Description
The rotator cuff is a group of 4 muscles that help move the shoulder. The muscles attach to the bones around the ball-and-socket joint by a thick, non-elastic tissue called a tendon. Tendons can tear by an acute injury or degenerate over time. Tears can occur in any of the 4 tendons. In order of commonality, the supraspinatus is most often injured, followed by the infraspinatus, subscapularis and teres minor. Rotator cuff arthropathy is defined as arthritis with a large rotator cuff tear.
What are the causes?
Rotator cuff tears have multiple causes. Acute trauma, longstanding impingement syndrome (caused by abrasion on the acromion or bone spurs at the AC joint), repetitive overhead activities and degeneration in the older population are all common. When the tendons are detached from the bone, the shoulder becomes dysfunctional. Pain is associated with motion of the arm and motion eventually decreases if the tendons are not repaired back to the bone.
What are the symptoms?
Rotator cuff tears cause pain, particularly on the side of the shoulder and at night, leading the patient to believe they slept wrong on their shoulder. Subacromial bursitis typically accompanies rotator cuff tears. Depending on the severity and location of the tear, loss of motion and strength can occur in a specific plane. This may be lifting the arm to the side, overhead or behind their back. Activities of daily living like reaching up to a cupboard, reaching for a wallet in a back pocket, brushing your hair or fastening a bra may be severely impacted when a rotator cuff tear is present. A massive tear of more than one tendon may result in pseudoparalysis, an inability for the patient to move their arm away from their body. Pain may also radiate up the shoulder to the neck, as the patient attempts to move the shoulder using other muscles. If the tendons remain torn for an extended period of time, the ball does not stay centered in the joint, causing wear and tear to one or both sides of the ball-and-socket joint.
How is it diagnosed?
Dr. Liu will perform a thorough history and physical exam including X-rays. Exam findings will consist of loss of active range of motion (you move your arm), preserved passive range of motion (the surgeon moves your arm), weakness and pain with muscle testing. X-rays may or may not demonstrate acromion abnormalities or AC joint bone spurs that may be causing impingement of the rotator cuff. Superior or anterior movement of the humerus (ball) on X-ray is a sign of a chronic rotator cuff tear that may not be amenable to repair (also known as superior or anterior escape). MRI is useful to quantify the size, severity and age of the tear. For patients who cannot have an MRI, CT/”CAT” scan with contrast dye may be helpful in assessing damage to the rotator cuff.
Non-operative
The extent of the arthritis, long term damage to the tendons and muscles, function of the shoulder, amount of pain and patient factors (age, health issues like diabetes or seizure disorder, tobacco use and activity level) all influence the treatment of rotator cuff arthropathy. Non-operative treatment can be attempted but once the diagnosis of rotator cuff arthropathy is made, is not usually helpful. Physical therapy, anti-inflammatory medication, cryotherapy, activity modification or injections into the space just above the rotator cuff may alleviate pain and inflammation. Patients whose pain does not resolve with non-operative treatment should discuss surgical treatment options with their surgeon.
Platelet-rich plasma (PRP) injection is another non operative option for treating pain. Blood is taken from your arm and is spun down to get the healthiest healing factors - platelets and serum. The goal is to promote an anti-inflammatory effect, reduce pain, and stimulate healing. There is also the potential for joint preservation by slowing down the arthritic process. Although one injection may help, studies support a series of 2 injections, 1 x Week/2 weeks. Not covered by insurance.
Bone Marrow Concentrate "Stem Cell" Injections is another non operative option for treating pain. Bone marrow is aspirated from your pelvis and centrifuged in a special kit to concentrate stem cells, which are then re-injected into the joint. The goals are to change the living micro-environment of the joint to a positive one, and to decrease inflammation and cartilage cell death. Will promote healing of cartilage, will not re-grow cartilage, restore joint space, or remove bone spurs. There is also great potential for joint preservation by slowing down the arthritic process in early stages. Not covered by insurance.
Operative
Patients who have a chronic, irreparable tear in the rotator cuff but have minimal to no arthritis, several minimally invasive arthroscopic procedures can be performed for pain relief. An arthroscopic procedure, also known as a debridement or "cleanout", can remove inflammatory tissue, remove bone spurs and treat biceps tendon injury/inflammation. An arthroscopic superior capsular reconstruction (SCR) uses donor tissue to realign the ball-and-socket joint and restore some of the mechanics that are affected by chronic rotator cuff tendon tears. Both of these procedures may decrease pain, but restoration of function is patient dependent. For more advanced rotator cuff arthropathy with moderate to severe arthritis, reverse total shoulder arthroplasty can be performed for pain relief and restoration of some function. In a reverse arthroplasty, your surgeon can remove the arthritic areas of the ball-and-socket joint and replace them with metal and plastic components. In this procedure, the ball-and-socket components are switched, so that the ball becomes a socket and the socket becomes a ball, allowing the shoulder to move pain-free and using other muscles in lieu of the rotator cuff. Your surgeon will discuss all of your options based on the severity of damage in your shoulder.
Recovery
After surgery, your medical team will give you several doses of antibiotics to reduce your risk for infection, and pain medication to keep you comfortable. Most patients are able to eat solid food and get out of bed the day after surgery. You will most likely be able to go home on the second or third day after surgery.
Pain Management
After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.
Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few weeks of your surgery.
Rehabilitation
When you leave the hospital, your arm will be in a sling. Your surgeon may instruct you to do gentle range of motion exercises to increase your mobility and endurance. A formal physical therapy program may also be recommended to strengthen your shoulder and improve flexibility.
You should be able to eat, dress, and groom yourself within a few weeks after surgery.
Your surgeon may ask you to return for office visits and x-rays in order to monitor your shoulder.
Do's and Dont's After Surgery
- Do follow the home exercise program prescribed by your doctor.
- Do avoid extreme arm positions, such as behind your body or your arm straight out to the side for the first 6 weeks.
- Don't overdo it.
- Don't lift anything heavier than 5 lbs. for the first 6 weeks after surgery.
- Don't push yourself up out of a chair or bed, as this requires forceful muscle contractions.
- Don't participate in repetitive heavy lifting after shoulder replacement.
Long-Term Outcomes
After rehabilitation, you will most likely be able to lift your arm to just above shoulder height and bend your elbow to reach the top of your head or into a cupboard. Reverse total shoulder replacement provides outstanding pain relief and patient satisfaction is typically very high.
Early and mid-term studies of the results of this surgery have been very promising. Currently, very few long-term studies exist. This is an area for future research.