Seattle Rotator Cuff Tear Treatment

Rotator Cuff Tear - Surgery versus Rehabilitation

Rotator cuff tears are a common source of shoulder pain. The incidence of rotator cuff damage increases with age and is most frequently due to degeneration of the tendon, rather than injury from sports or trauma. While the information that follows can be used as a guide for all types of rotator cuff tears, it is intended specifically for complete degenerative tears of the rotator cuff. Treatment recommendations vary from rehabilitation to surgical repair of the torn tendon(s). The best method of treatment is different for every patient. The decision on how to treat rotator cuff tears is based on the patient's severity of symptoms and functional requirements, and presence of other illnesses that may complicate treatment. In consultation with an orthopaedic surgeon, the information that follows is intended to assist patients in deciding on the best management of their rotator cuff tear with the understanding that all patients are unique.

Anatomy and Pathophysiology

The rotator cuff is a group of four muscles that surround the humeral head (ball of joint). The muscles are referred to as the SITS muscles-Supraspinatus, Infraspinatus, Teres minor and Subcapularis. The muscles function to provide rotation and elevate the arm and give stability to the shoulder joint (glenohumeral joint). The supraspinatus is most frequently involved in degenerative tears of the rotator cuff. More than one tendon can be involved. There is a bursa (sac) between the rotator cuff and acromion that allows the muscles to glide freely when moving. When rotator cuff tendons are injured or damaged, this bursa often becomes inflamed and painful.

Pain, loss of motion and weakness may occur when one of the rotator cuff tendons tears. The tendons generally tear off or at their insertion (attachment) onto the humeral head.

Incidence

Rotator cuff tears increase in frequency with age, are more common in the dominant arm, and can be present in the opposite shoulder even if there is no pain. The true incidence of rotator cuff tears in the general population is hard to determine because 5 percent to 40 percent of people without shoulder pain may have a torn rotator cuff. This was determined by studies using MRI and ultrasound to image the shoulders of patients with no symptoms. One study6 revealed a 34 percent overall incidence of rotator cuff tears. The highest incidence occurred in patients who were more than 60 years old. This study supported the concept that rotator cuff damage has a degenerative component and, importantly, that a tear of the rotator cuff is compatible with a painless, normal functioning shoulder.

Etiology

There are intrinsic and extrinsic causes of rotator cuff tears. An example of an intrinsic factor is tendon blood supply. The blood supply to the rotator cuff diminishes with age and transiently with certain motions and activities. The diminished blood supply may contribute to tendon degeneration and complete tearing. The substance of the tendon itself degenerates over time. Due to an age related decrease in tendon blood supply, the body's ability to repair tendon damage is decreased with age; this can ultimately lead to a full-thickness tear of the rotator cuff.

An extrinsic cause would be damage to the rotator cuff from bones spurs underneath the acromion. The spurs rub on the tendon when the arm is elevated; this is often referred to as impingement syndrome. Bone spurs are another result of the aging process. The rubbing of the tendon on the bone spur can lead to attrition (weakening) of the tendon. Combining this with a diminished blood supply, the tendons have a limited ability to heal themselves. These factors are at least partly responsible for the age-related increase in rotator cuff disease and the higher frequency in the dominant arm.

Seattle Rotator Cuff Tear Treatment Pic 2 This diagram depicts a bone spur on the undersurface of the acromion. Repetitive rubbing of the bone spur on the rotator cuff can weaken the tendon. During surgery to repair a torn rotator cuff, the spur is often removed to relieve the impingement. Removing the spur is referred to as an acromioplasty.

Natural History

What will happen if a torn rotator cuff is not treated with surgery? Will I lose the use of my arm? Will the tear get larger over time? These are common concerns patients have, and the answers are not always clear. In one study, 40 percent of patients with a rotator cuff tear showed enlargement of the tear over a five-year period; however, 20 percent of those patients had no symptoms. Therefore, less than half of patients with a rotator cuff tear will have tear enlargement, but 80 percent of patients whose tear enlarges will develop symptoms. This data is based on a small group of patients; it is important to realize that once symptoms develop, progression may have already progressed and enlarged.

Edwin D. Vyhmeister MD and C. Hendrik Kirchhoff MD - Providing services in hand and wrist injury surgery, tennis elbow and shoulder rehab and tendinitis treatment to the areas of Everett and Seattle, Washington.