With summer here, patients are out enjoying activities such as golf, paddling on the river, tennis and fly fishing. I often see patients in the office who present with shoulder pain after participating in these sorts of overhead activities. Typically patients do not report a particular injury but just notice that the shoulder pain has been steadily increasing. The pain is usually worse when doing overhead sports or overhead work. It may wake patients up at night from sleep. Often, this shoulder pain is due to rotator cuff inflammation or rotator cuff tendon tearing.
The rotator cuff is the coalescence of 4 tendons: the subscapularis, supraspinatus, infraspinatus and teres minor. These 4 tendons attach to the top of the arm bone (head of the humerus). As we age, these tendons fray and can tear. There are studies that show that up to 50% of people over the age of 60 have partial or full tears of one or more rotator cuff tendon. In some individuals, these tears may not be painful. However, in most patients rotator cuff tearing is very painful. Patients often report to me that the pain is worst at night when trying to sleep. In the office, a good physical exam of the rotator cuff can indicate a tear and then an MRI is used to confirm the diagnosis.
Rotator cuff tears have very limited healing potential as there is poor blood supply to the area of the tear. The majority of partial rotator cuff tendon tears actually progress to full tears over time. As more time passes, torn tendons further retract from their native attachment sites and become even bigger tears.
Patients with partial rotator cuff tendon tears can usually be treated without surgery. Physical therapy is prescribed to restore full range of motion and strength. Occasionally an injection is performed to reduce inflammation and pain, and rest and avoidance of repetitive overhead activities is recommended.
Active patients with full tears of one or more of their rotator cuff tendons who fail nonsurgical management are treated with arthroscopic rotator cuff repair surgery. The torn tendons are mobilized and freed up from any adhesions. A small burr is used to lightly abrade the bone where the tendons normally attach so that stem cells and healing cells are released from the bone. Small bone anchors are placed in the bone where the tendons normally attached. Sutures from these anchors are then passed up through the torn tendons and secured. Newer repair techniques allow better fixation of the torn tendon back to the bone thus improving surgical outcomes.
Some tendon tears are so large and retracted that they cannot be mobilized and stretched back to the bone. Up until a few years ago, I had little to offer patients with massive, irreparable rotator cuff tendon tears. However, now there is a newer technique whereby a donor tissue patch can be arthroscopically sutured into the irreparable tendon defect and the results from this have been very promising.
After surgery, patients wear a sling for 6-8 weeks to protect the tendon repair so that the tendons can slowly grow back into the bone and heal. Very gentle range of motion exercises are started immediately after surgery and later physical therapy is begun. The biggest problem that patients report after rotator cuff surgery is difficulty sleeping due to pain. The recovery time after arthroscopic rotator cuff repair surgery is unfortunately a number of months as it takes a long time for the repaired tendons to grow back into the bone and for people to recover the strength they had lost. However, most patients do very well with this surgery and can ultimately get back to doing the activities that they enjoy.