Shoulder - Rotator Cuff Tear

Description

The shoulder is a ball and shallow socket joint. The shoulder is kept in the socket by your rotator cuff muscles. The rotator cuff is a group of four muscles that surround the shoulder joint. The muscles attach to the bone by thickened portions of non-elastic tissue called tendons. The rotator cuff is responsible for the majority of motion that occurs at the shoulder. Tears can occur in any of the four tendons. In order of commonality, the supraspinatus is most often injured, followed by the infraspinatus, subscapularis and teres minor. Tears in the tendons can either be partial or complete.

There are two main types of rotator cuff tears, acute and degenerative tears. 

Acute tears can happen with trauma, like falling on an outstretched hand, or lifting something too heavy with a jerking motion. Degenerative tears happen with longstanding impingement syndrome, repetitive overhead activities and degeneration in the older population are all common.

Symptoms

Most common symptoms of a rotator cuff tear include:

  • pain, particularly on the side of the shoulder and at night
  • pain when lifting or lowering the arm
  • weakness

This pain may be when 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.

Diagnosis 

Dr. Liu will perform a thorough history and physical exam including X-rays. Exam findings can 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 (aka-superior or anterior escape). MRI is useful to quantify the size, severity and age of the tear. For patients that cannot have an MRI, CT/”CAT” scan with contrast dye may be helpful in assessing damage to the rotator cuff.

If you have a rotator cuff tear and you keep using it, this can result in further damage. A rotator cuff tear can get larger over time. Early treatment can prevent your tear from getting worse. The goal of treatment is to decrease pain and increase function. 

Non-operative

Non-operative treatment can be attempted in patients with partial tears of the rotator cuff, or small tears with minimal symptoms. Physical therapy, anti-inflammatory medication, rest and activity modification are mainstays of non operative treatment. Corticosteroid injections into the space just above the rotator cuff may alleviate pain and inflammation. 

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. Once injected, the platelets degranulate and release activate growth factors and cytokines to promote healing. A one time leukocyte rich, concentrated PRP injection can be recommended for intrasubstance tears. One injection may be all you need, however, there are times where multiple injections may provide additional benefit. Not covered by insurance.

Bone Marrow Concentrate "Stem Cell" Injections is another non operative option for treating pain, usually only an option for partial thickness tears. Bone marrow is aspirated from your pelvis and centrifuged in a special kit to concentrate stem cells, which are then reinjected into the tendon. The goals are to change the living microenvironment of the tendon, up regulating collagen formation, and promote tendon cell healing and reorganization.  Not covered by insurance. 

Patients whose pain does not resolve with non-operative treatment should discuss surgical treatment options with their surgeon.

Operative

Partial tears that fail to improve with non-operative treatment can be treated with a minimally-invasive arthroscopic procedure. Depending on the tear pattern and quality of the tissue, the partial tear can be “cleaned-up” (aka – debrided) or repaired. If the tear is due to an acromion abnormality or bone spur from AC joint arthritis, a subacromial decompression can be performed to eliminate the cause of the tear.

Tears in which the tendon has completely detached from the bone should be surgically repaired, as they cannot heal on their own. Dr. Liu performs a minimally-invasive arthroscopic procedure to repair the rotator cuff tendon. 

Following rotator cuff repair, your surgeon will recommend a sling to protect the repair while it heals, and start physical therapy to regain motion and strength in the shoulder. The length of time in a sling and the start of physical therapy are based on the type of tear, tissue quality and ability to heal, among other factors. 

In cases where the rotator cuff cannot be repaired the surgeon can choose to debride the torn tendon and attempt a partial rotator cuff repair for pain relief and function. A minimally-invasive arthroscopic superior capsular reconstruction (SCR) can be completed in a young active patient without arthritic changes and in the presence of an irreparable rotator cuff tear for pain relief and potentially some restoration of motion.

Finally, a reverse total shoulder replacement can be performed for pain relief and potentially some restoration of motion if soft tissue repair is not possible.

Coming Soon!