Rotator cuff repair

Answer 1

Definition

Rotator cuff repair is a type of surgery to fix a torn tendon in the shoulder. The procedure can be done with a large ("open") incision or with shoulder arthroscopy, which uses small button-hole sized incisions.

Description

The rotator cuff is a group of muscles and tendons that form a cuff over the shoulder joint. These muscles and tendons hold the arm in its "ball and socket" joint and help the shoulder to rotate. The role of the tendons is to hold the powerful shoulder muscles to the shoulder and arm bones. The tendons can be torn from overuse or injury.

Your doctor will first check your shoulder with a small camera (arthroscope) to look at the tear and determine if it can be fixed. The arthroscope is inserted into the shoulder through a small poke-hole. The camera is connected to a video monitor. The surgeon looks around the entire joint to check the cartilage, tendons, and ligaments of your shoulder.

After evaluating the shoulder joint, the surgeon places the camera in the space above the rotator cuff tendons, called the subacromial space. The surgeon can check the area above the rotator cuff, clean out inflamed or damaged tissue, and remove a bone spur (subacromial spur).

If a tear is going to be fixed, the surgeon may perform the surgery with a larger, open incision. Other surgeons use the arthroscope and 1 to 3 additional small poke-holes or smaller incisions to perform the surgery. The additional small incisions allow the surgeon to insert other instruments to repair damaged tissue.

The goal is to attach the tendon back to the bone where it tore off. The tendon is attached with sutures. Small rivets (called suture anchors) are often used to help attach the tendon to the bone. The suture anchors can be made of metal or material that dissolves over time, and do not need to be removed.

At the end of the surgery, the incisions are closed, and a dressing is applied. If arthroscopy was performed, most surgeons take pictures of the procedure from the video monitor to show you what was found and what was done.

Why the Procedure Is Performed

Rotator cuff repair may be recommended for shoulder problems such as:

• Torn rotator cuff with weakness and pain
• Pain, especially using the arm overhead
• A bone spur or inflammation around the rotator cuff

Risks

The risks for any anesthesia are:

• Allergic reactions to medications
• Problems breathing

The risks for any surgery are:

• Bleeding
• Infection
• Nerve damage

Additional risks include:

• Stiffness of the shoulder
• Failure of the surgery to relieve symptoms
• Failure of the repair to heal
• Weakness of the shoulder

After the Procedure

Surgery to repair a torn rotator cuff is usually very successful at relieving pain in the shoulder. The procedure may not always return strength to the shoulder. Rotator cuff repair can require a long recovery period, especially if the tear was large.

In many cases, arthroscopy reduces the need to surgically open the shoulder joint. This can result in less pain and stiffness. In cases of repair, the body still needs to heal after arthroscopic surgery, just as if it were open surgery, so the overall recovery time will still be long.

Outlook (Prognosis)

The recovery can take anywhere from 3 to 6 months, depending on the size of the tear and other factors. You may have to wear a sling for 1 to 6 weeks after surgery. Pain is usually managed with medications.

When you can return to work or play sports will depend on the surgery that was performed, but it will usually take several months to resume your regular activities.

Physical therapy may help you to regain the motion and strength of your shoulder. The length of therapy will depend on the repair that was performed.

References

Matsen FA III, Fehringer EV, Lippitt SB, Wirth MA, Rockwood CA Jr. Rotator cuff. In: Rockwood CA Jr, Matsen FA III, Wirth MA, Lippitt SB, eds. The Shoulder. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 17.

Miller RH II, Dlabach JA. Shoulder and elbow injuries. In: Canale ST, Beatty JH, eds. Campbell's Operative Orthopaedics. 11th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 44.

Answer 2

Definition

The rotator cuff is a group of muscles and tendons that attach to the bones of the shoulder joint, allowing the shoulder to move and keeping it stable.

• Rotator cuff tendinitis refers to irritation of these tendons and inflammation of the bursa (a normally smooth layer) lining these tendons.
• A rotator cuff tear occurs when one of the tendons is torn from overuse or injury.

Alternative Names

Swimmer's shoulder; Pitcher's shoulder; Shoulder impingement syndrome; Tennis shoulder; Tendinitis - rotator cuff; Rotator cuff tendinitis; Shoulder overuse syndrome

Causes, incidence, and risk factors

The shoulder joint is a ball and socket type joint where the top part of the arm bone (humerus) forms a joint with the shoulder blade (scapula). The rotator cuff holds the head of the humerus into the scapula and controls movement of the shoulder joint.

The tendons of the rotator cuff pass underneath a bony area on their way to attaching the top part of the arm bone. When these tendons become inflamed, they can become more frayed over this area during shoulder movements. Sometimes, a bone spur may narrow the space even more.

This problem is called rotator cuff tendinitis, or impingement syndrome, and may be due to:

• Keeping the arm in the same position for long periods of time, such as doing computer work or hairstyling
• Sleeping on the same arm each night
• Playing sports requiring the arm to be moved over the head repeatedly as in tennis, Baseball (particularly pitching), swimming, and lifting weights over the head.
• Working with the arm overhead for many hours or days (such as painters and carpenters)
• Poor control or coordination of your shoulder and shoulder blade muscles

Poor posture over many years and the usual fraying of the tendons that occurs with age may also lead to rotator cuff tendinitis.

Rotator cuff tears may occur in two ways:

• A sudden or acute tear may happen when you fall onto your arm while it is stretched out, or after a sudden, jerking motion when trying to lift something heavy.
• A chronic tear of the rotator cuff tendon occurs slowly over time. It is more likely in those with chronic tendinitis or impingement syndrome. At some point, the tendon wears down and tears.

There are two types of rotator cuff tears:

• A partial tear is when a tear does not completely sever the attachments to the bone.
• A complete or full thickness tear refers to a through and through tear. It may be as small as a pinpoint or all of the muscle tendon. Complete tears have detachment of the tendon from the attachment site and would not heal very well.

Symptoms

TENDINITIS OR IMPINGEMENT SYNDROME

Early on, pain occurs with overhead activities and lifting your arm to the side. Activities include brushing hair, reaching for objects on shelves, or playing an overhead sport.

• Pain is more likely in the front of the shoulder and may radiate to the side of the arm. However, this pain always stops before the elbow. If the pain travels beyond the arm to the elbow and hand, this may indicate a pinched nerve.
• There may also be pain with lowering the shoulder from a raised position.

At first, this pain may be mild and occur only with certain movements of the arm. Over time, pain may be present at rest or at night, especially when lying on the affected shoulder.

You may have weakness and loss of motion when raising the arm above your head. Your shoulder can feel stiff with lifting or movement. It may become more difficult to place the arm behind your back.

ROTATOR CUFF TEARS

The pain with a sudden tear after a fall or injury is usually intense. Weakness of the shoulder and arm is often present, along with a snapping sensation of movement.

Symptoms of a chronic rotator cuff tear include a gradual worsening of pain, weakness, and stiffness or loss of motion. The exact point when a rotator cuff tear begins in someone with chronic shoulder tendinitis may or may not be noticed.

Most people with rotator cuff tendon tears have pain at night. Pain that is worse at night may wake you up. During the day, the pain is more tolerable and hurts with certain movements.

Over time, the symptoms become much worse and are not relived by medicines, rest, or exercise.

Signs and tests

A physical examination may reveal tenderness over the shoulder. Pain may occur when the shoulder is raised overhead. There is usually weakness of the shoulder when it is placed in certain positions.

X-rays of the shoulder may show a bone spur. They can be done in your doctor's office.

If your doctor feels you may have a rotator cuff tear, you may have one or more of the following tests:

• An ultrasound test uses sound waves to create an image of the shoulder joint. It can often show a tear in the rotator cuff.
• MRI of the shoulder may show swelling or a tear in the rotator cuff.

Sometimes, a special imaging test called arthrography is needed to diagnose a rotator cuff tear. Your doctor will inject contrast material into your shoulder joint. Then either an x-ray, CT scan, or MRI scan are used to take a picture of it. Contrast is usually used when your doctor suspects a small rotator cuff tear.

Treatment

TENDINITIS OR IMPINGEMENT SYNDROME

Treatment involves resting the shoulder and avoiding activities that cause pain. It may involve:

• Ice packs applied 20 minutes at a time, 3 - 4 times a day to the shoulder
• Taking drugs like ibuprofen and naproxen to help reduce swelling and pain
• Avoiding or reducing activities that cause or worsen your symptoms to worsen

For more information about managing your symptoms at home and returning to sports or other activities, see Rotator cuff - self-care.

You should start physical therapy to learn exercises to stretch and strengthen the muscles of your rotator cuff.

If the pain persists or if therapy is not possible because of severe pain, a steroid injection may reduce pain and swelling in the injured tendons, to allow effective therapy.

With rest and exercise, symptoms often improve or go away. However, this may take weeks or months to occur.

Arthroscopic surgery can remove inflamed tissue and part of the bone that lies over the rotator cuff. Removing the bone may relieve the pressure on the tendons.

ROTATOR CUFF TEARS

Someone with a partial rotator cuff tear who does not normally place a lot of demand on the shoulder can try rest and exercise.

If the rotator cuff has had a complete tear, or if the symptoms persist despite conservative therapy, surgery to repair the tendon may be needed. Most of the time, arthroscopic surgery can be used. Some large tears require open surgery to repair the torn tendon.

Expectations (prognosis)

Many people recover full function after a combination of medications, physical therapy, and steroid injections after an episode of rotator cuff tendinitis. Some may need to change or reduce the amount of time they play certain sports to remain pain-free.

People with tears of their rotator cuff tend to do well, although their outcome is strongly dependent upon the size of the tear and how long the tear has been present, as well as their age and pre-injury level of function.

Calling your health care provider

Call for an appointment with your health care provider if persistent shoulder pain occurs. Also call if symptoms do not improve with treatment.

Prevention

Avoid repetitive overhead movements. Develop shoulder strength in opposing muscle groups.

See also: Rotator cuff - self-care

References

Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008;77(4):493-497.

Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008;77(4):453-460.

Greiwe RM, Ahmad CS. Management of the throwing shoulder: cuff, labrum and internal impingement. Orthop Clin North Am. 2010 Jul;41(3):309-23.

Matsen III FA, Fehringer EV, Lippitt SB, Wirth MA, Rockwood Jr. CA. Rotator cuff. In: Rockwood CA Jr, Matsen FA III, Wirth MA, Lippitt SB, eds. The Shoulder. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 17.

Seida JC, LeBlanc C, Schouten JR, Mousavi SS, Hartling L, Vandermeer B, Tjosvold L, Sheps DM. Systematic review: nonoperative and operative treatments for rotator cuff tears. Ann Intern Med. 2010 Aug 17;153(4):246-55.

Reviewed By

Review Date: 07/06/2011

C. Benjamin Ma, MD, Assistant Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Answer 3

Definition

Rotator cuff repair is a type of surgery to repair a torn tendon in the shoulder. The procedure can be done with a large ("open") incision or with shoulder arthroscopy, which uses small button-hole sized incisions.

Description

The rotator cuff is a group of muscles and tendons that form a cuff over the shoulder joint. These muscles and tendons hold the arm in its "ball and socket" joint and help the shoulder to rotate and move. The role of the tendons is to hold the powerful shoulder muscles to the shoulder and arm bones. The tendons can be torn from overuse or injury.

Your surgeon will first check your shoulder with a small camera (arthroscope) to look at the tear and determine if it can be fixed. The arthroscope is inserted into the shoulder through a small poke-hole. The camera is connected to a video monitor. The surgeon looks around the entire joint to check the cartilage, tendons, and ligaments of your shoulder.

After evaluating the shoulder joint, the surgeon places the camera in the space above the rotator cuff tendons, called the subacromial space. The surgeon can check the area above the rotator cuff, clean out the inflamed or damaged tissue, and remove a bone spur (subacromial spur).

If a tear is going to be fixed, the surgeon may perform the surgery with a larger, open incision. Other surgeons can use the arthroscope and 1 to 3 additional small poke-holes or smaller incisions to perform the surgery. The additional small incisions allow the surgeon to insert other instruments to repair damaged tissue.

The goal is to attach the tendon back to the bone where it tore off. The tendon is attached with sutures. Small rivets (called suture anchors) are often used to help attach the tendon to the bone. The suture anchors can be made of metal or material that dissolves over time, and do not need to be removed. Sutures are attached to the anchors, which tie the tendon back to the bone.

At the end of the surgery, the incisions are closed, and a dressing is applied. If arthroscopy was performed, most surgeons take pictures of the procedure from the video monitor to show you what was found and what was done.

Why the Procedure Is Performed

Reasons rotator cuff repair may be done include:

• You have shoulder pain when you rest or at night, and it has not improved with exercises over 6 - 12 months.
• You have a large or complete rotator cuff tear.
• You are active and use your shoulder for sports or work.
• You have a lot of weakness and are unable to do everyday activities.

Surgery is a good choice in a person whose tear was caused by a recent injury. It is also a good choice when the tendons of the rotator cuff were not already frayed from chronic rotator cuff problems.

Some patients with a partial tear may choose not to have surgery, using rest and exercise instead. The best candidates for this approach are those who have only a partial tear and do not place a lot of demand on their shoulder.

• Shoulder pain will improve with this approach.
• However, any weakness will not improve, the tear become larger over time, and you may be limited in the sports or other act ivies you can do.

Risks

The risks for any anesthesia are:

• Allergic reactions to medications
• Problems breathing

The risks for any surgery are:

• Bleeding
• Infection
• Nerve damage

After the Procedure

Recovery can take anywhere from 3 - 6 months, depending on the size of the tear and other factors. You may have to wear a sling for 4 - 6 weeks after surgery. Pain is usually managed with medications.

You will be wearing a sling when you leave the hospital. Some patients also wear a shoulder immobilizer. This keeps your shoulder from moving. How long you wear the sling or immobilizer will depend on the type of surgery you had.

Physical therapy may help you to regain the motion and strength of your shoulder. The length of therapy will depend on the repair that was performed.

See also:

• Shoulder surgery - discharge
• Using your shoulder after surgery

Outlook (Prognosis)

Surgery to repair a torn rotator cuff is usually very successful at relieving pain in the shoulder. The procedure may not always return strength to the shoulder. Rotator cuff repair can require a long recovery period, especially if the tear was large.

When you can return to work or play sports will depend on the surgery that was performed, but it will usually take several months to resume your regular activities.

Some rotator cuff tears may not fully heal. Stiffness, weakness, and chronic pain may still be present.

These poorer results are more likely when the following are present:

• The rotator cuff was already frayed or weak before the injury.
• Larger tears
• After-surgery exercise and instructions are not followed
• Older patients (over age 65)
• Smoking

References

Elkousy HA, Edwards TB. Shoulder: Development of skills for shoulder surgery. In: DeLee JC, Drez D Jr, Miller MD, eds. DeLee and Drez's Orthopaedic Sports Medicine. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 17, section Q.

Miller RH II, Dlabach JA. Shoulder and elbow injuries. In: Canale ST, Beatty JH, eds. Campbell's Operative Orthopaedics. 11th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 44.

Seida JC, LeBlanc C, Schouten JR, Mousavi SS, Hartling L, Vandermeer B, Tjosvold L, Sheps DM. Systematic review: nonoperative and operative treatments for rotator cuff tears. Ann Intern Med. 2010 Aug 17;153(4):246-55.

Reviewed By

Review Date: 06/30/2011

Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington, School of Medicine; and C. Benjamin Ma, MD, Assistant Professor, Chief, Sports Medicine and Shoulder Service, UCSF Dept of Orthopaedic Surgery. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Answer 4

Alternate Names

Shoulder exercises

Your Shoulder Joint

The rotator cuff is a group of muscles and tendons that attach to the bones of the shoulder joint, allowing the shoulder to move and keeping it stable.

The tendons of the rotator cuff pass underneath a bony area on their way to attaching the top of the arm bone. These tendons join together to form a cuff that surrounds the shoulder joint. This provides the stability of the joint and allows movement of the arm bone on the shoulder bone.

Injury to these tendons may result in:

• Rotator cuff tendinitis, when irritation and swelling of these tendons is present
• A rotator cuff tear, when one of the tendons is torn due to overuse or injury.

See also: Rotator cuff problems

These injuries often lead to pain, weakness, and stiffness when you use your shoulder. A key part in your recovery is starting exercises to make the muscles and tendons in your joint stronger and more flexible.

Your doctor may refer you to a physical therapist to treat your rotator cuff. A physical therapist is trained to help improve your ability to do the activities you want.

Muscle Strengthening and Stretching

Many muscles surround your shoulder and lower back. When all of these muscles are working together well, they serve to stabilize your shoulder joint. When your shoulder is stabilized, there is less strain on your shoulder joint and muscles when you are active.

Before treating you, a doctor or therapist will evaluate your body mechanics. The therapist may:

• Watch how your shoulder moves as you perform activities, including your shoulder joint and your shoulder blade
• Observe your spine and posture as you stand or sit
• Check the range of motion of your shoulder joint and spine.
• Test different muscles for weakness or stiffness
• Check to see which movements seem to cause or worsen your pain

After testing and examining you, your physical therapist or doctor will know which muscles are too weak or too tight. You will then start a program to stretch out your muscles and make them stronger.

The goal is to teach you proper techniques for using your shoulder with everyday activities, at work, or during sports activities. Exercises can help you heal from an injury and avoid re-injury.

See Rotator cuff - self care to learn how to take care of your shoulder and avoid placing extra stress on it.

If you just had surgery to repair your rotator cuff, see also:

• Shoulder surgery - discharge
• Using your shoulder after surgery

Exercises for Your Shoulder

The goal is for you to function as well as possible with little or no pain. To do this, your physical therapist will treat your shoulder pain, help you strengthen and stretch the muscles around your shoulder, and teach you proper techniques to move your shoulder, for either everyday tasks or sports activities.

Before doing exercises, have your doctor or physical therapist make sure you are doing them properly. If you have pain during or after an exercise, the way you are doing the exercise may need to be changed.

Most exercises for your shoulder work to either strengthen (make stronger) or stretch the muscles and tendons of your shoulder joint.

Exercises to stretch your shoulder include:

• Stretching the back of your shoulder (posterior stretching)
• Hand up your back stretch (anterior shoulder stretch)
• Anterior shoulder stretch - towel
• Pendulum exercise
• Wall stretches

Exercises to strengthen your shoulder:

• Internal rotation exercise - with band
• External rotation exercise - with band
• Isometric shoulder exercises
• Wall push-ups
• Shoulder blade (scapular) retraction - no tubing
• Shoulder blade (scapular) retraction - tubing
• Arm reach

Reviewed By

Review Date: 07/06/2011

C. Benjamin Ma, MD, Assistant Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Answer 5

Rotator Cuff Problems

The rotator cuff is a group of muscles and tendons that attach to the bones of the shoulder joint, allowing the shoulder to move and keeping it stable.

• Rotator cuff tendinitis refers to irritation of these tendons and inflammation of the bursa (a normally smooth layer) lining these tendons.
• A rotator cuff tear occurs when one of the tendons is torn from overuse or injury.

Relieving the Pain

Drugs like ibuprofen and naproxen will help reduce swelling and pain. If you are taking these medicines every day, make sure that you tell your health care provider so that they can monitor your general health.

Ice packs applied to the shoulder 20 minutes at a time, 3 - 4 times a day, can help when your shoulder is painful.

Using Your Shoulder

Learning how to take care of your shoulders to avoid placing extra stress on them can help you heal from an injury and avoid re-injury.

Your position and posture during the day and night can help relieve some of your shoulder pain:

• When sleeping, lay either on your back or side that is not painful. Resting your painful shoulder on a couple of pillows may help.
• When sitting, use good posture. This means keeping your head over your shoulder and your shoulders back, a towel or pillow behind your lower back, your feet either flat on the floor or up on a foot stool.

A few other tips for taking care of your shoulder include:

• Avoid carrying a backpack or purse over just one shoulder.
• Avoid working with your arms above shoulder level for very long. If needed, use a foot stool or ladder.
• Lift and carry objects close to your body. Try not to lift heavy loads away from your body.
• Take regular breaks for any activity you are doing over and over again.
• When reaching for something with your arm, your thumb should be pointing up.

Consider making some changes around your home so it is easier for you to take care of yourself. Store everyday items you use in places you can reach easily. Keep things with you that you use a lot, like your phone.

Physical Therapy and Exercises

Your surgeon will refer you to a physical therapist to learn exercises for your shoulder.

• You'll probably start with passive exercises. These are exercises the therapist will do with your arm. They help get the full movement back in your shoulder.
• After that you will do exercises the therapist teaches you. These will help increase the strength in your shoulder and the muscles around your shoulder.

Returning to Sports

Over all, it is best to avoid sports activity until you have no pain during rest or any activity. Also, when examined by your doctor or physical therapist, you should have:

• Full strength in the muscles around your shoulder joint
• Good range of motion of your shoulder blade and upper spine
• No pain during certain physical exam tests that are meant to provoke pain in someone who still has rotator cuff problems
• No abnormal movement of your shoulder joint and shoulder blade

While you may feel impatient and want to push the timeframe of your recovery, you should think about a few points. If you return to sports too soon, the way you use your shoulder and your elbow, spine, and hip will be different. Your risk of injury to any of these areas increases.

Returning to any demanding sport should be gradual and not at full force in the beginning. Ask your physical therapist about the proper technique you should use when doing your sports activity.

References

III FA, Fehringer EV, Lippitt SB, Wirth MA, Rockwood Jr. CA. Rotator cuff. In: Rockwood CA Jr, Matsen FA III, Wirth MA, Lippitt SB, eds. The Shoulder. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 17.

Greiwe RM, Ahmad CS. Management of the throwing shoulder: cuff, labrum and internal impingement. Orthop Clin North Am. 2010 Jul;41(3):309-23.

Reviewed By

Review Date: 07/06/2011

C. Benjamin Ma, MD, Assistant Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.