Addressing your rotator cuff!

I have been operating on shoulders with the arthroscope since 1987. That makes me one of a handful of local surgeons who have been doing this long enough to better appreciate IF and WHEN to do this surgery. Over the years, the indications for surgery and definitely the outcomes of this procedure have changed, not only in techniques, but in expected outcomes.  In my practice, the number of patients that ultimately need arthroscopic rotator cuff surgery has decreased dramatically.  

It is important to understand the following:

1) Just because you have pain in your shoulder, does not mean it is just from your shoulder. I see a lot of patients after “Rotator Cuff” surgery that still have pain. Is it still their cuff? Or was it the nerves from the neck and or an inflammatory process?  In many of my patients, what comes in as “shoulder pain” is something else.

2) MRI’s:  An MRI reads findings in the shoulder only.  These findings are not necessarily what is causing your pain!  A rotator cuff tear may be present, but the symptoms may be from an arthritic shoulder joint, an arthritic AC (Acromial-Clavicular) joint, Nerves, Neck, Shingles, inflammatory process, etc.  Keep in mind, in some series most shoulders show changes in their rotator cuff after the age of thirty.  If you are over 50 years of age, over 20% of patients have FULL Rotator cuff tears in ASSYMPTOMATIC shoulders.  In other words, after 50 you have a 1 in 5 chance of a full rotator cuff tear just being alive, so just because you just started having shoulder pain and just got your first MRI and there is a tear, doesn’t mean it just tore!

3) In many studies- and they are all over the place as far as reported results, ½, yes about HALF of the repairs did not heal, or re-tore soon after the surgery.  Why?  In my opinion, they tear due to age so they don’t heal due to age.

4) The long-term findings in large “meta-analysis” studies have suggested that rotator cuff repair “does not provide either a clinically or statistically significant benefit over nonoperative treatment”.

 

OK! So, having pointed out this “data”, do I still operate on shoulders with rotator cuff pathology? YES, YES! But only if I think I can benefit the patient, the patient has failed all non-operative means (Conservative care), and I think at least some of the pain is coming from the shoulder.  I also insist that patients understand what I just stated as far as natural history and long-term success rates. 

What is the Rotator Cuff?

The rotator cuff is four muscles underneath your big Deltoid that connect your scapula (Shoulder blade) to the ball.  Each muscle has a specific function in stabilizing the ball in the shallow cup in different positions of the arm.  Thus, a tear of any particular muscle can lead to a specific weakness noted in the exam.

What to expect in the exam

I need X-Rays. These tell me more than most MR’S.  Is there spurring? Is there cancer? Is there a lesion in the chest wall? Is there osteopenia, Is there a new or old fracture? Is there narrowing indicative of a torn muscle, etc…

In a full exam.  I am looking for abnormalities in motion—stiffness for example (Do you have a frozen shoulder, etc.)  I am looking at weaknesses in some part of your shoulder ESPECIALLY compared to the opposite shoulder.  

Many patients require at least ONE cortisone shot with NUMBING medicine and NUMBING spray!  Not only can the shot be therapeutic it also HELPS DEFINE what is causing the shoulder pain!  For example, if I put a shot into the cuff pathology and one gets NO RELIEF then I am going to assume the pain in the shoulder may be coming from other sources, such as the neck.  If half the pain goes away then half is from the area of the shot.  Another shot may be required in another area, for example the AC joint.  Depending on the response from that also, I can figure out if its just the rotator cuff pathology and or ALSO the AC joint, for example.

Treatment    

As a rule, most patients will require non-operative treatment because most patients will succeed with non-operative treatment.  This is usually a combination of the correct exercises, Anti-inflammatories, occasional injections, and avoidance of offending activities.  Physical Therapy may be ordered, but not indefinitely, not only because the insurance companies usually have limits, but because one needs to learn to do their own exercises for decades of relief.  

 

Surgery

Surgery is indicated for only two reasons in my practice.

1) Pain, that is unacceptable to the patient (not the doctor) that fails conservative care.

2) Weakness, that is unacceptable to the patient (not the doctor) that fails conservative care.

Almost all surgeries are performed with the arthroscope.  I determine ahead of time if the patient will want his rotator cuff repaired if repairable.

Why would the patient not want his rotator cuff repaired?  As this article started, only ½ of the repaired rotator cuffs heal.  Second of all, the repaired rotator cuff patient requires one month in a sling, followed by 4 more months of gradual, restricted lifting. Third, at least people in my practice get relief simply from me removing the associated spurs. This does not require any restrictions after two weeks.  

If an MRI is obtained before the surgery I still establish if the patient does or doesn’t want his rotator cuff repaired.  MRI” s can be wrong. If it says it isn’t torn, yet I see one, what do I do if I haven’t already obtained permission to repair or not repair said cuff?

So, basically, if one fails conservative treatment and I think part or all of the pain is coming from the shoulder, I will definitely “clean up the shoulder”, including the common spurring, BUT I will leave the decision of repairing the cuff up to the patient, now knowing the ½ failure to heal and the post-op limitations.  As an aside, most of my ranchers, for example, are going out the next week and “drive” T-Posts so I know fixing theirs is not going to work.

 

MRI’S    

Most of our surgical decisions comes from the response of the shots, the medications and exercises.  MRI’s, in my opinion, have a 10% false positive and a 10% false negative. I will recommend surgery to “decompress” and repair the rotator cuff if the patient wants it repaired (Again ½ heal and it requires restricted lifting for a few months).  I personally don’t repair “partial tears” although I don’t fault those that do!   I feel most partial tears do ok with the decompression.  If one were to repair a partial tear, it first is converted into a full tear , then repaired as a full tear.  1/2 then don’t heal, right?  

However, many insurance companies require one because the person “approving” the surgery has nothing to look at other than my notes, your progress, and the indications.  So that expense to you is because of the insurance requirements.

I do get an occasional MRI!  At times I simply cannot figure out why an abnormal pain pattern or response exists. The MRI may be of the neck also, because of that abnormal pain.  Also in the case of acute traumatic tears such as severe weakness following a shoulder dislocation, or ski/motorcycle wreck in which I am looking for a fresh tear of potentially multiple tendons.

MRI’s are useful, but they aren’t cheap to many of my patients with high deductibles, so I order them with caution KNOWING this burdensome expense and knowing that WHAT I see at the time of surgery is more important than what a radiologist unfamiliar with YOUR symptoms reads on a scan.

These are my opinions based on a combination of my training and my years of experience!