Rotator Cuff Tears: Anatomy
The rotator cuff is actually made up of 4 tendons that form a “cuff” and insert onto the humerus (you may know it as your arm) on a boney prominence known as the greater and lesser tuberosity. Rotator cuff tears involve tendons tearing from this area of the bone.
Tears are quite common in the supraspinatus tendon as well as infraspinatus. Why this occurs is still a subject of exploration in the orthopaedic literature, but may be a mix of poor blood supply, tissue degeneration, mechanical abrasion, and trauma. However we do know that by the age of 60 nearly half of the population has a tear, and most are degenerative tears. The larger the tear the larger decrease in function. These tears do NOT heal on their own, and do tend to grow incrementally over time. That does not mean that you need surgery! While, rotator cuff surgery is the most commonly done surgery in Dr. Schwartz’s practice, it is also likely the most commonly nonoperative problem as well.
Rotator cuff tears can range in size from small to large; this is a video of a rotator cuff surgery of a more complex tear pattern of not only the supraspinatus and infraspinatus but also the subscapularis.
Rotator Cuff Tears: Treatment
Tears often respond well to conservative treatments, and I personally prefer to exhaust these before even discussing surgery for the reasons listed below. NSAIDs (like ibuprofen/naproxen), physical therapy, and judicious use of cortisone injections should be considered before surgical intervention. When surgically indicated, I perform this surgery arthrosopically through incisions roughly the size of your pinkie finger, on an outpatient basis. Postoperatively, you can expect to be in a sling for 6 weeks to allow the tendon time to heal to the bone (surgery just fixes it securely to the bone, it does not heal it! Your body needs time for this), with rehabilitation to start afterwards.
Rotator cuff surgery is honestly one of the most difficult experiences a patient can expect to go through. The typical conversation with Dr. Schwartz will stress that this surgery will put you through Five Key Things:
- A LOT OF PAIN – Seriously, some people state that the surgery produces some of the worst pain of their lifetime. Obviously, we try to minimize that through icing, appropriate narcotics, minimally invasive surgery; but to call it an unpainful operation would be a lie.
- Sleep is difficult. It usually already is prior to an operation due to the pain from the ruptured tendons in the shoulder. After surgery it definitely is. A recliner is handy to sleep in or stack some pillows so that you sleep upright. Sleep usually improves in 4-6 weeks after the operation. This is a common problem in the postoperative period.
- There is a period of immobilization. This can range from the type of tear that you have, but will usually be between 3-6 weeks depending on your tear pattern. The consequence of immobilizing the shoulder is that it allows your shoulder to heal, and the tendons to heal; however, your shoulder will get stiff which requires….
- DAILY PHYSICAL THERAPY. Dr. Schwartz will give you the option to rehab your shoulder on your own or to use physical therapy. Using formal PT is not an excuse to not work on your shoulder on a daily basis. The more work that you put into your shoulder, the more quickly you’ll get a functional shoulder out of this experience. Postoperative pain is driven by stiffness, so as stiffness works itself out, patient satisfaction usually improves.
- Milestones: Usually 80% of normal range of motion (ROM) by 3 months, 90-95% by 4-6 months. Pain improves a lot by 4 months out, and usually you will finally be happy that you had the operation by 4 months out. You will not like Dr. Schwartz until 4 months out.
Anyone that sugar coats any of these issues to you is not giving you a full story. These reasons are why we try to exhaust nonoperative treatment for most rotator cuff tears before proceeding to rotator cuff surgery. There are obviously exceptions to these rules, and exceptional patients as well. Larger tears usually rehab faster, paradoxically, than small tears. Traumatic tears (a sudden pop with a large loss of shoulder function) should not be treated non operatively; these sudden acute traumatic tears do much better with surgery.
If you have a rotator cuff tear and are tired of dealing with the inability to do what you want with you life, call Dr. Schwartz’s office now for an appointment 206-668-6100, or contact us for more information.