young female tennis player injured shoulderAddressing Your Rotator Cuff Injury

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.  

What You Should Know About Rotator Cuff Repair

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.

Can I have a rotator cuff injury without a tear?

You would describe a tear as an acute injury, but the rotator cuff can also suffer chronic sorts of injuries. Just as with any joint, the shoulder is susceptible to damage from long-term use. This leads to progressive degeneration or wear and tear of the tendon tissue. Unlike the weakness described above when you have torn the rotator cuff, inflammation caused by natural deterioration will usually begin to show itself in dull aching deep within the shoulder.

What are the different types of rotator cuff injuries?

You can break rotator cuff injuries into either being acute or chronic.

  • Acute injuries — Tears and strains to the rotator cuff occur from a singular traumatic incident, such as putting your arm out to break a fall. If these injuries are strains, they may heal over time with rest and proper treatment.
  • Chronic injuries — These injuries result from overuse or entrapment/impingement of the rotator cuff. Repeated motions, such as a baseball pitcher or a construction worker hammering overhead, can lead to chronic injuries. These are defined as ongoing conditions with symptoms lasting 6 weeks or longer. These types of rotator cuff injuries are treated by Dr. Holmes with a combination of pain control, rest, and rehabilitation.

What are the symptoms of a torn rotator cuff?

Pain and weakness in your shoulder are the signs you have torn your rotator cuff. The degree of damage dictates the extent of your symptoms. You will have persistent pain, tenderness, weakness, and you won’t be able to move your shoulder through a full range of motion. The most pain will accompany movements such as reaching directly above your head, reaching behind your back, and during lifting motions involving your shoulder. Something as innocuous as combing your hair will become very painful. Over time, you will feel pain even when the shoulder is at rest, particularly when lying on your side in bed.

Acute tears are intensely painful and can be accompanied by a snapping sensation if the tendon has fully ruptured.

What are the common causes of rotator cuff injuries?

These injuries, as mentioned above, are the result of a traumatic event, such as a fall with an outstretched arm, or from long-term, progressive degeneration. Repeated overhead lifting or other movements, such as painting, over a prolonged period of time can damage the tendon.

There are certain factors that increase your risk of rotator cuff injury:

  • Age — Rotator cuff tears are most common in people over the age of 60.
  • Construction jobs — Carpenters, house painters, and others who use repetitive arm motions, frequently overhead, can damage their rotator cuff over time.
  • Family history — These injuries seem to have a genetic component, as they can be common in certain families.
  • SPORTS – certain sports that require repetitive arm motions.

When should I see a doctor for my shoulder pain?

Shoulder pain can be a common part of life, particularly as we move past 60. The question of when it is time to see a specialist such as Dr. Holmes is a case of how much the pain is negatively impacting your life. If you’re having to stop doing certain things because of your shoulder pain, this may not be a tradeoff you’re willing to make. Otherwise, some chronic soreness may be easily managed with over-the-counter pain relievers prior to an activity that could cause some pain.

The one case where you need to seek immediate attention is if you suffer immediate weakness in your arm after an injury. This could point to a torn rotator cuff, and this merits a closer look from Dr. Holmes.

Questions? Give Us A Call

What to expect in a shoulder 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 it is just the rotator cuff pathology and or ALSO the AC joint, for example.

Rotator Cuff Treatment Options

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.  

 

Rotator Cuff 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!

What can happen if I don’t treat a rotator cuff injury?

Shot of a sporty young man suffering from a sports injury outdoorsAlthough cases such as a rotator cuff strain can improve on their own, it’s usually a good idea to have your shoulder pain checked out. That’s obvious if you’ve suffered an acute injury and you have no strength or you can no longer even raise your arm above your chest level.

But chronic pain can be ignored as the person thinks it’s just part of getting older. That’s not necessarily true. Experienced orthopedic surgeons/specialists, such as Dr. Holmes, can help you address what’s behind your pain. People assume they will need complicated rotator cuff surgery where a lengthy rehabilitation period is necessary, but Dr. Holmes looks at surgery as only a last resort. He exhausts all conservative treatment options first, everything from physical therapy to possible corticosteroid injections.

If your rotator cuff is degenerating or chronically inflamed, it’s likely to get worse. Then it will begin to impact your daily life more and more. Combing your hair. Pulling on a sweater. Reaching up in a closet. All of these simple routine tasks will become painful.

There’s no reason to ignore shoulder pain that could be due to a rotator cuff injury. All you have to lose is the pain you’re dealing with.

Is physical therapy an effective treatment for a rotator cuff injury?

Almost all tears and tendonitis can be initially treated with structured home exercises and occasional physical therapy. Once pain and range of motion issues have been addressed, if prescribed, PT can focus on strengthening the rotator cuff; correcting strength and flexibility issues; and addressing stability and mobility issues involving the shoulder blade at the back of the shoulder. Take out last sentence

Physical therapy can also be used to show the patient how to change the repetitive motions that are leading to their chronic inflammation.

What will my recovery from rotator cuff surgery entail?

Your recovery will be dictated to a degree by which method was used for your surgery. Regardless of the method Dr. Holmes uses, take out section our entire team at Sports Occupational and Knee Surgery is with you through this entire process to ensure your best final outcome.

Although Dr. Holmes most often uses arthroscopic methods if at all possible, some cases require the open method. If you’ve had open surgery, you’ll likely spend at least one night in the hospital.

Once home, there are no shortcuts here if you want a successful end result. Your dedication to rehabilitation will directly impact your return of motion and function in your repaired shoulder. Your rehabilitation will involve Immobilization which is meant to protect your surgically repaired tendon. You will wear a sling to keep your arm from moving and will not be able to use it. The length of this phase depends on the type of surgery and severity of your tear but will last about 4 weeks. It’s important to respect the injury and repair and to not place any stress on the shoulder during this time.
Physical therapy for arthroscopic techniques is seldom advised. Dr. Holmes will instruct you in customized passive and active exercises.

Full recovery can take up to 6 months, with adequate strength and function coming somewhere between 4 to 6 months after surgery. It is important not to rush things with your recovery.

Schedule a Consultation

To learn more about shoulder pain treatment options, including surgical and nonsurgical solutions, schedule an appointment with Dr. Holmes. Our office can be reached at (210) 696-9000. We serve San Antonio, TX and surrounding areas.