Rotator Cuff Disease
Introduction / Anatomy
Rotator cuff disease is a common disorder and results in significant pain and dysfunction in the shoulder. Four muscles envelop and attach to the wingbone or scapula and each blends into a tendon which travels out over the ball or humeral head to anchor to the upper arm bone or humerus. The four tendons blend together around the ball and form a “cuff” or covering over the humeral head. The muscles and rotator cuff or sheet of tendon tissue serve to stabilize the ball in the socket and rotate the arm. The rotator cuff travels out beneath the roof of the shoulder or acromion. With frequent or heavy use of the shoulder, the rotator cuff may become worn or “threadbare” and develop a partial-thickness or eventually a full-thickness tear or hole (figure 1). Tears typically grow larger and the rotator cuff muscles become weaker over time. With age and use of the shoulder, bone spurs may develop on the roof of the shoulder, impinge on tendon tissue and contribute to rotator cuff damage.
Pain, popping, snapping and weakness may accompany reaching, pulling, or lifting when a rotator cuff tear is present. These symptoms may follow a new injury or gradually develop with inflammation over time. Pain may be vague in location, but is often present over the side of the upper arm and occasionally radiates up toward the side of the neck. Night pain is a common complaint. Gradual loss of motion, or stiffness, may result as well.
A careful history and physical examination often suggests the possibility of rotator cuff disease. Tenderness, restricted motion, and rotator cuff weakness are often present. X-rays may reveal bone spurs on the roof of the shoulder (acromion) or decreased space between the ball and the roof of the shoulder (less room for the rotator cuff to function). Occasionally, calcium will deposit in the cuff tendon tissue and is often visible on the X-ray image. An MRI is the most accurate imaging study to evaluate the integrity of the rotator cuff. The extent, location, and size of the tear can be estimated along with the extent of muscle atrophy or shrinkage due to disuse.
An inflamed or frayed rotator cuff is usually managed non-operatively with ice, anti-inflammatories, gentle stretching and strengthening exercises along with physical therapy. Non-operative treatment is successful in 85% of patients without a significant tear. In selected cases, a cortisone injection may provide excellent relief of pain.
For those patients who do not respond to these conservative measures, the rotator cuff can be debrided (shaving of loose, ragged ends) and impinging spurs removed from the roof of the shoulder. This is done with the aid of an arthroscope or lighted lens instrument which is introduced into the shoulder through a small cannula approximately the size of a pencil. Additional instruments are introduced at other sites around the shoulder. A small motorized burr with attached suction is used to “plane off” any spurs or hooks which encroach on the rotator cuff.
Arthroscopic Cuff Repair
Over the past fifteen years, we have participated in the development of minimally-invasive techniques to complete rotator cuff repairs using only arthroscopic instruments delivered through small cannulas. There is typically less pain and scar formation with easier restoration of shoulder range-of-motion. Special miniature instruments are used to prepare the cuff tendon tissue, insert tiny metallic or absorbable bone anchors (figure 2), and pass and tie sutures or stitches (figure 3). These methods secure the rotator cuff to the bone from which it tore and permit eventual healing (figure 4). Arthroscopic rotator cuff repair is performed on an outpatient basis. For surgeons experienced in the minimally-invasive techniques, arthroscopic rotator cuff repair offers less insult to the shoulder, particularly the deltoid muscle, and healing rates equal to those for open repair.
A padded sling is worn for the first four weeks after surgery. The day following the operation, the dressings over the small arthroscopic incisions are removed and band-aids applied. There are no sutures to remove. Gentle passive range-of-motion exercises are begun the day following surgery. Formal physical therapy is started after one week and continues two to three times each week for the first month and then one to two times each week for a second month. Motion is restored first, and then strengthening exercises are implemented. Rotator cuff healing is relatively slow given its poor blood supply. Simple activities of daily living begin the second week. Lifting, pushing and pulling are avoided during the first six weeks. Recovery of shoulder function occurs gradually over a period of six months. Those employed in an office setting usually return to work after one week and those who lift and push during their workday may require as long as four months to return to fairly full activities. Light activities such as a golf swing begin after three months.