According to some studies, more than one in five adults has been found to have a rotator cuff tear. This common shoulder injury can occur as a result of trauma, such as a fall, or as a result of general “wear and tear” (degenerative rotator cuff tears).
Dr. Wurth is a board-certified orthopaedic surgeon specializing in treatment of the shoulder, elbow, hand and wrist and is a fellow in the American Academy of Orthopaedic Surgeons.
WS: How prevalent are rotator cuff tears?
Rotator cuff tears are very common. There are basically two types of rotator cuff tears. The first type is traumatic rotator cuff tears, which occur when someone has an injury or fall. These are typically accompanied by immediate onset of pain in the shoulder, weakness and dysfunction. The second type of rotator cuff tear is degenerative. These “wear and tear” injuries occur with time and use. Degenerative rotator cuff tears increase in frequency as you age. They make up the majority of rotator cuff tears that are treated both surgically and non-surgically.
WS: If someone is experiencing shoulder pain, when should they come see you?
The most common complaints I hear from people who have rotator cuff tears are shoulder pain with activity and pain at night. Nighttime pain is very characteristic. When pain persists and begins to interfere with your daily activities, you should see an orthopaedic specialist.
WS: Can you help us understand what’s happening in the shoulder when a rotator cuff tear occurs?
The rotator cuff is made up of four tendons around the shoulder. Tendons connect muscles to bones. A rotator cuff tear occurs when the tendon pulls off the bone. Once that’s happened, it will never heal on its own. Surgery is the only avenue for a torn tendon to heal back to the bone.
WS: So does everyone with a rotator cuff tear undergo surgery?
Not necessarily. Treatment is very patient-specific. If I have a 50-55-year-old with a rotator cuff tear, I may be a little more aggressive treating that injury with surgery than a 75-year-old with a rotator cuff tear. Also, traumatic tears (from injury) tend to do worse than degenerative tears when treated non-operatively.
You can manage rotator cuff tears non-operatively by administering an injection to reduce pain and inflammation, followed by therapy to strengthen the portions of the rotator cuff tendons that are not torn. You can try to strengthen the front and back portions of the rotator cuff that are still intact. By doing so, you get the other tendons and muscles working in concert to move the shoulder despite the torn portions. In essence, the goal is that they can ‘pick up the slack’ for the portions that are torn.
If you can treat the tear with therapy and the pain settles down and you’re relatively pain-free, it’s okay to go on with life and treat the issue non-operatively. However, patients should remain aware a rotator cuff tear is still present. If pain returns and is persistent, it could be an indication that pathology is progressing, and surgical intervention should be considered.
WS: When it comes to surgical treatment, have there been any recent technological advancements in your field changing how patients receive care for rotator cuff tears?
Rotator cuff repair surgery, from a biological standpoint, has always been the same. It’s a matter of getting the torn tendon reattached to the bone and holding it there until it’s healed. However, the surgical procedure has gone through a lot of changes over time.
Today, we have a wide variety of options. We use something called suture anchors. I explain to patients that they’re like drywall tacks for bone. You make a punch in the bone and screw in these little anchors, which have sutures that come off of them. You pass those sutures through the rotator cuff tendon tissue and use those sutures to pull the tendon back to the bone.
There has been a substantial leap in arthroscopic advancement of rotator cuff repair over the last 20 years. Today, we tend to do the vast majority of our repairs arthroscopically, which means we use a camera and make small holes with working cannulas that go through the skin, soft tissue, and deltoid muscle. The cannulas go into the area around the rotator cuff. We inflate the area with sterile water to allow visualization and fix the damaged tendons with the help of the camera. This helps reduce postoperative pain since we no longer have to make a large incision in the deltoid muscle.
WS: Speaking of post-op, what’s the recovery process like?
First, it’s a misconception to think an arthroscopic approach allows the rotator cuff to heal quicker, because it doesn’t. Biology is biology, and it takes time for the tendon to heal itself to the bone. That’s what drives the postoperative protocol and rehab after rotator cuff repairs.
I keep my postoperative protocol fairly simple. I put patients in a sling and small pillow that allows the arm to stay away from the body, taking tension off the repair and creating more comfort for patients. Patients wear that sling for about six weeks and they do therapy – typically beginning as soon as two days post-op.
Patients do passive range of motion therapy for the first six weeks, during which the therapist moves the arm for them. After two weeks, I have the therapist provide the patient with pulleys that they can attach to the door at home which allow them to stretch the repaired shoulder with power from their good shoulder.
At six weeks, I discontinue the sling and pillow begin active (on their own) and active-assisted (with the help of therapist) range of motion while continuing with passive range of motion exercises.
I do not incorporate strengthening of the rotator cuff with bands until week ten because biologically, it takes roughly ten weeks before the repaired tendon begins to adhere and put down fibers that attach it to the bone. It’s at that point when the tendon starts developing structural integrity. Typically by week 12, I tell people they’ll be back to most of their daily activities. However, I wait until four months before I release patients to unrestricted activities. There’s no sense in trying to push too fast with regards to rotator cuff repairs and the actual healing process. Biology is biology. Give the tendon time to heal.
WS: How does the collaborative approach of The Bone and Joint Institute help patients receive the best care?
Dr. Wurth: Our team of surgeons are on the forefront of orthopaedic care. We routinely hold conferences in which we discuss interesting and difficult cases. Great care often comes from multiple opinions rather than just one. Our patients benefit from our practice’s spirit of collaboration amongst its surgeons. We are all more than happy to work together to make sure patients have the very best outcomes possible.
The desire for good outcomes extends to our facility as well. We designed our surgery center to take care of orthopaedic patients. Our operating rooms are designed specifically for that purpose and our ASC staff are trained solely for orthopaedic care. It’s an exceptional place to practice orthopaedics and receive care.
WS: It must be rewarding to provide care that helps patients get back to doing what they love. What do you enjoy most about your work?
I get to see patients across the whole experience, from the time they walk in and they’re in pain – scared to a degree – oftentimes dealing with a problem that is affecting their entire life. In many instances they are unable to work due to their injuries. We discuss their injury, present options for care, formulate a plan, and execute the treatment.
During this process, I go from the individual who fixes the structural problem on the front end to the individual who is an advocate for their recovery on the back end. I take pride in my patients’ success. It’s always so rewarding for me to see my patients on their last visit walk out and say ‘thank you for what you’ve done for me.’ That’s what brings me back to work every day. I couldn’t see myself doing anything else in medicine.
Rotator Cuff Repair at The Bone and Joint Institute
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