OrthoVirginia is experiencing technical difficulties as the result of a cybersecurity incident. The incident is impacting our phone and network servers. Our IT team and third-party cybersecurity professionals were immediately engaged to investigate and restore our systems. While that investigation is ongoing, at this time we have no evidence that any patient data was impacted as a result of this incident. As our inquiry into this matter progresses, we will continue to provide updates as appropriate. In the meantime, you may experience delayed responses to phone messages. We are continuing to see patients as normal. For more information on how to contact us during this time, visit orthovirginia.com/contact-options
 

OrthoVirginia is requiring ALL patients & visitors to wear a MASK at ALL times. Read our COVID-19 policies

Understanding Shoulder Rotator Cuff Injuries and Treatment

by Matthew Walker, MD

Understanding Shoulder Rotator Cuff Injuries and Treatment

Let’s talk about rotator cuff tears, a topic near and dear to my heart. I’m going to tell you a little bit of what I know about rotator cuffs and how we can help you get through some shoulder pain that might be related to rotator cuff problems.

So, first things first…

What is the rotator cuff?

The rotator cuff is a group of four muscles and tendons that surround the shoulder. It has three important jobs.

  1. Elevate the arm.
  2. Rotate the shoulder (where it gets its name).
  3. Keep the shoulder centered on the socket.

The four muscles in the rotator cuff are the

  1. Supraspinatus, the top tendon.
  2. Infraspinatus, the top-back tendon.
  3. Teres minor, a small tendon in the back of the shoulder.
  4. Subscapularis, the biggest muscle in the front of the shoulder.

What are rotator cuff conditions or injuries?

Rotator cuff problems come in all shapes and sizes. Most of these issues can be divided into tendonitis, partial tears, or full tears of the rotator cuff. The rotator cuff is important to discuss because most people are going to be affected by rotator cuff issues at some point in their life.

Almost everyone has suffered from shoulder pain. Most of the time, that pain falls into a rotator cuff tendonitis category, but you can have partial tears. Up to 60% of patients who are over 60 years old have full thickness rotator cuff tears.

The reason you can have both a partial and full thickness tear is because the rotator cuff is made up of multiple layers of tissue just like how toilet paper is made of two plies. The rotator cuff has its own layers of tissue. There are five layers in the rotator cuff, and you can have injuries or tears involving one or multiple tissue layers.

What are the treatment options?

What we do to treat you depends on how extensive those tears are and how you respond to certain therapies. Partial tears involve superficial fibers of the tendon. Up to 80% or 90% of the time, full thickness tears mean all five layers of the tendons are completely torn and detached. For most partial thickness tears, we implement treatments such as injections, physical therapy, and things of that nature. Most full thickness tears require some form of surgical intervention. If tendonitis of the rotator cuff is giving you symptoms, we can try injections, physical therapy, and anti-inflammatories. The vast majority of rotator cuff injuries that are not full tears can be treated with anti-inflammatories, cortisone shots, Toradol shots, or physical therapy.

Full thickness tears come in two categories: symptomatic vs. asymptomatic.

As I said earlier, 60% of patients age 60 and over have full thickness rotator cuff tears, but that doesn’t mean that everybody with a tear has symptoms. We tend to not repair asymptomatic rotator cuff tears. For symptomatic tears that are giving you pain, giving you weakness, and limiting your function, we recommend surgery.

Most rotator cuff surgeries these days are treated with an outpatient surgical procedure. Most of the time, we’re doing that surgery arthroscopically, meaning through cameras and using small incisions. The problem with rotator cuff surgery is that it’s a long recovery. I always tell patients that I get the easy job, and you get the hard job. What I mean by that is the surgery takes 45 minutes or so, and you go home the same day. You have small incisions around three to five and half inches around the shoulder, but the recovery takes a long time.

We repair the tendon to the bone, and it takes three months for that tendon to heal back down to the bone. So, we have to protect you for that whole three-month period of time. Now, that doesn’t mean that in three months you walk into the office, and your shoulder feels great. The shoulder will be weak and stiff. You’ve got to get your shoulder strength back. The recovery for rotator cuff surgery is really more like 10% per month recovery. It takes almost a year for the shoulder to feel as good and strong as it’s going to be before you’re back to 100%.

What are the symptoms of rotator cuff issues?

Shoulder pain from rotator cuff issues tends to be on the side of the arm in the anterior lateral aspect (the outside of the shoulder). People describe it as a dull, achy, gnawing type pain. It’s often worse at nighttime. When you lay down flat, it hurts. With activities, you’re weak. When you do day-to-day things such as pouring a pot of coffee, reaching across your body to get the seatbelt, reaching behind you to unhook your bra strap, or tucking your shirt in behind your back, all of these activities can cause pain if you have rotator cuff issues.

Rotator cuff pain doesn’t typically go along the shoulder blade in the back. It doesn’t typically travel all the way down to your arm or your hand. If we find that those are some of your symptoms, we tend to look for other things that might be causing those problems.

Frequently asked questions

What is the difference between rotator cuff tears and frozen shoulder?

One of the I think most misdiagnosed things I see in my office is a frozen shoulder. A frozen shoulder is caused by thickening of the lining or the capsule of the shoulder. It’s an inflammatory process. Inflammation causes a frozen shoulder. The inflammation that normally would go away in a couple weeks stays around, and it causes the lining to thicken up and scar.

It’s extremely painful. You lose motion both actively and passively which means you can’t raise your arm a certain amount and I, the physician, can’t raise your arm a certain amount either. It’s stuck.

The rotator cuff is different from the lining of the shoulder. It’s the muscles and the tendons that surround the shoulder. Sometimes, the symptoms can overlap, but you typically don’t get as stiff with rotator cuff injuries or tears as you do with a frozen shoulder.

I’ve had an MRI to confirm I have a rotator cuff tear. Does putting off the surgery make it worse?

The tear can grow with time, and the muscles can undergo fatty changes, which means the tendon has torn off the bone, and the muscle has nothing to pull against. Over time, the muscle wears out and turns into fat. Once the muscles undergo fatty changes, it’s not typically a good idea to repair the rotator cuff because they don’t heal very well. So, waiting for a period of time can make the tear worse both from a size standpoint, meaning the tear can get bigger, and from a tissue quality standpoint which means the tendon can get thinner, and the muscles can undergo fatty changes.

We usually advise fixing rotator cuff tears as soon as possible. It’s hard nowadays because of the pandemic, but most facilities that we use for operations are undergoing pretty regimented protocols to screen patients and to screen guests. We’re limiting people coming into the hospital and into the surgery centers.

I have a complete tendon tear, but I can still raise my arm. Is this unusual?

That is actually the more common presentation of rotator cuff injuries. It’s usually something that’s going on for a period of time, and usually people can still raise their arm. The reason why is because the rotator cuff has four muscle-tendon units. Most tears are not huge tears involving all of those muscles and tendons. They tend to be tears that are one to three centimeters in diameter or width. Those are small to medium tears.

Patients still have the ability to raise their arm, and they can still do day-to-day things, but they tend to have some pain. So, being able to use the arm and move it and raise it above your head does not necessarily mean that the rotator cuff is intact. You can have a small tear but still have enough function of the remaining muscles to let you do some of those things.

Is lifting weights good or bad for shoulders?

I tell patients I don’t want you to restrict your activities just in case something might be bad for your shoulder. I don’t think the human body is made to lift heavy weights. So, if you’re bench pressing around 400 pounds, that might not be the best thing for your rotator cuffs. But I think moderate exercise with moderate weights and higher reps are all good things for your body.

The health benefits you get from working out and exercising outweigh the problems that might be caused by rotator cuff tears. Day-to-day things that you can do to protect your rotator cuffs are keeping your elbows close to your side when you pick up heavy objects. For example, if you’re putting a heavy cooler on the back of the pickup truck, you don’t want to keep your arms all the way out in front of you. Keep your elbows close to your side. When you’re starting the lawnmower, pull it away where your elbow stays close to your body. Those things will help minimize stress and strain on the rotator cuff.

How long is the shoulder immobilized after surgery?

Depends a little bit on the size of the tear and on surgeon preference.

If you have a full thickness tear, and you come to my office, and we fix your rotator cuff, I’m going to keep you in the sling for six weeks. The first six weeks you’re not doing a whole lot. You’re coming out to bend and extend your elbows. You’re doing some small circles with the arm. But you’re not doing much more than that.

I don’t even start you on physical therapy until the sling comes off. So, six weeks for me. Some people might keep you in the sling for four weeks. Some people who have a massive rotator cuff tear might be in the sling for eight weeks, but I think six weeks is a good one to think about in your mind.

After surgery, do I have to sleep in a recliner? Or can I sleep in my bed?

One of the biggest problems with shoulder pain and shoulder surgery is nighttime. At nighttime, everything seems to hurt worse on the shoulder. It seems that sleeping in a more upright position is more comfortable than lying flat. There’s no real medical reason to sleep in the recliner except that it might make you more comfortable.

So, you can sleep in the bed. I do tell patients that want to sleep in the bed to put pillows behind the back so they’re upright somewhat.