What is the rotator cuff and how is it injured?
Your rotator cuff is a group of tendons of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. The rotator cuff holds the humeral head in the glenoid (shoulder socket) and provides stability to your shoulder. It can become torn and/or frayed from simple wear and tear/degeneration, repetitive overhead activity, or direct trauma (i.e motor vehicle accident, a fall, pulling on arm). The incidence of rotator cuff tears increases with age and is less common in patients younger than 40 years old.
What are symptoms of a rotator cuff tear?
- Pain in the shoulder that may radiate down the side of the arm
- Pain worse at night
- Pain worse with overhead activity
- Weakness with large tears
If your doctor suspects a rotator cuff injury by history and physical exam, he will often order a MRI. This is the best test for evaluating the rotator cuff.
How do we treat rotator cuff tears non-operatively?
- Anti-inflammatory medications- These decrease inflammation and, therefore, decrease pain.
- Cortisone shots- steroids are very potent anti-inflammatory medications and go directly to the source with little systemic absorption.
- Physical Therapy- strengthening the remaining intact rotator cuff stabilizes the shoulder. This is the initial treatment of choice for partial- thickness tears.
- Surgery- most full-thickness tears of significant size should be surgically repaired. The fully-torn cuff will not heal down to the bone without help and the tear will likely get bigger. Surgery is usually arthroscopic but, occasionally, an open incision is required.
What is shoulder arthroscopy?
Shoulder arthroscopy is a surgical procedure using a small camera to view the shoulder joint through small incisions. The camera is inserted into the shoulder joint and a complete inventory of the shoulder is performed. Your surgeon is able to see your shoulder joint in detail and can repair or remove damaged tissue.
How is shoulder arthroscopy performed?
First, the anesthesiologist administers a nerve block in pre-op that typically lasts 12-18 hours but can last up to 36 hours. You are then placed under general anesthesia and your shoulder is examined to test your shoulder without muscle resistance. The camera is then placed into your shoulder through a small incision. A complete inventory of your shoulder is performed looking at all the structures in your joint. Additional portals are made for the insertion of the working instruments. If a rotator cuff tear is present, the goal is to fix it to its anatomic position by using suture anchors. These are specialized screws with attached sutures that are screwed into the bone and the sutures are passed through the tissue to fix the cuff to bone.
Sometimes, other parts of the shoulder also cause pain and can be addressed at the time of surgery. The biceps tendon can have some fraying or tendonitis that can be treated by simply debriding the tendon, releasing the tendon (tenotomy), or cutting the tendon and sewing it down to bone (tenodesis). There also can be acromioclavicular joint arthritis that can be treated by taking out the end of the collarbone/clavicle (distal clavicle resection). Sometimes, a bone spur is found on the shoulder blade bone (acromion) which can impinge on the rotator cuff, causing pain. Making the bone spur smooth can decrease pain (subacromial decompression).
When you wake up, you will be in a sling and your incisions are stitched together and white steri-strips are placed over your incisions. Your shoulder will also be wrapped in a dressing. Keep your dressing clean, dry, and intact for 3 days post-op. You can shower post-op day 3, scrubbing your neck and letting the soapy water run over your incisions. Do not scrub your incisions. You will be sent home with pain medication and a medicine for nausea.
Complications of shoulder arthroscopy occur infrequently but can include and are not limited to bleeding, infection, persistent or increased pain, damage to nerves, blood vessels or cartilage, or worsening condition.
In most cases, you go home the same day. With a successful pre-op block, you will be comfortable but be sure to take your pain medication when you get home before your block wears off. You will wake up in a sling which is to be worn at all times in the first 72 hours. After 72 hours, you may take it off only to shower then put it back on. It is easiest to wear a button-up shirt. Ice 20 minutes every hour. Follow up with your surgeon 3-5 days post-op.
Physical therapy is prescribed to restore your motion and strength. The amount of therapy that you will need depends on what type of surgery was performed. Physical therapy is very important in optimizing your outcome. It is hard to estimate when you can return back to work or sport, as each surgery is highly variable. It is important to anticipate the expected length of recovery; it often can be estimated before surgery. This may vary based on the surgery performed, abnormalities found during surgery, or your specific sport or occupation.
Range of motion exercises are started passively at 1 week by your therapist. Depending on your surgery, certain motion restrictions may be in place. You begin active range of motion (moving your shoulder by yourself) at 1 month. Continue to wear the sling for the first month and thereafter in uncontrolled environments. Strengthening begins at 8-12 weeks. Full recovery may take 4-6 months depending on your sport or occupation. You can drive when you are off all narcotic pain medications and no longer require the sling. Ask your doctor before you drive and practice in a parking lot first.