Rotator Cuff Tears

Rotator cuff tears are one of the most common injuries of the shoulder. The anatomy of the shoulder is a ball-and-socket joint made up of three bones: the humerus (upper arm bone), scapula (shoulder blade), and clavicle (collarbone). The rotator cuff is comprised of 4 muscles and keeps the arm in the shoulder socket and provides stability.
 

There are two main types of tears:

1. Partial Tear
2. Full Thickness or Complete Tear

Tears are primarily caused by acute injury or overuse. Acute tears are the result of injury, such as falling on an outstretched arm or lifting a heavy object. With acute injuries, it is not uncommon to see other injuries present as well. 

Tears caused by overuse or degeneration occur over time and can be the result of the following:

•  Repetitive motion of the shoulder (i.e.  lifting, throwing, overhead work)
• Blood supply – as we age, the blood supply to the rotator cuff tendon decreases leaving the rotator cuff more susceptible to injury
• Shoulder impingement

Symptoms of a rotator cuff tear include:

• Pain at rest and/or at night
• Pain with lifting
• Weakness
• Cracking in the shoulder

Treatment of rotator cuff tears depends on the severity of the tear. Partial tears can often be treated non-surgically with physical therapy, rest, ice and anti-inflammatory medication. For full thickness tears, surgical intervention is recommended. Surgery is performed arthroscopically through a small incision in the shoulder. 

In surgical repair, bio-absorbable anchors are used to reattach the rotator cuff to its anatomically correct position. In our practice, we use a “double row” technique to reinforce the repair, reduce the risk of a repeat tear and enable healing. 

Some physicians recommend moving the shoulder immediately following surgery, however, we disagree. We recommend immobilizing the shoulder for approximately 3-4 weeks post-op. The Center for Special Surgery agrees and published an article on how immobilization following rotator cuff surgery leads to better healing. For a full overview, please see our previous post from August 2012. 

Rotator cuff tears are common and treatable. Early intervention in the case of degenerative tears can help prevent the need for surgical intervention. Advocare Orthopedic and Sports Medicine is here to help. Call to schedule your appointment: 973-300-1553 or follow us at facebook.com/johnvitolomd.

Common Injuries of the Rotator Cuff

The rotator cuff is a group of muscles and tendons in the shoulder. The rotator cuff allows for stability and movement of the shoulder. This piece of the anatomy is commonly injured as a result of overuse or acute injury.

There are five main conditions that involve the rotator cuff:

1. Rotator cuff tear
2. Rotator cuff tendonitis
3. Rotator cuff impingement
4. Frozen Shoulder
5. Subacromial Bursitis

Rotator Cuff Tears

Rotator cuff tears cause pain and weakness in the shoulder, making everyday activities difficult. People most at risk for a rotator cuff tear are those over 40 and those athletes or workers who engage in repetitive overhead and lifting activities. Treatment varies depending on the size/severity of the tear and the age/activity level of the patient. 

Rotator Cuff Tendonitis

Rotator cuff tendonitis occurs when the rotator cuff tendons become aggravated or inflamed. This causes pain in the shoulder. The pain is typically located in the front of the shoulder and sometimes extends to the upper arm. Tendonitis often occurs in conjunction with bursitis. The pain may make sleeping uncomfortable and sometimes a ‘clicking’ sound is heard when raising the arm.

Rotator Cuff Impingement

Rotator cuff impingement occurs when the rotator cuff is being pinched by the bones of the shoulder causing pain. Symptoms of impingement may develop gradually, with the pain becoming worse over time. When diagnosed early, impingement can generally be treated conservatively with physical therapy, ice, activity modification and anti-inflammatories.

Subacromial Bursitis

Subacromial Bursitis occurs when the bursa (the fluid filled sac located between the acromion and rotator cuff) becomes inflamed. The bursa acts as a cushion between the bones and tendons. When inflamed, pain is felt. Bursitis can typically be treated conservatively. 

Frozen Shoulder

Frozen shoulder or adhesive capsulitis causes pain and stiffness in the shoulder that becomes worse over time. Individuals between 40 and 60 years of age are more prone to this condition. Frozen shoulder can be debilitating, but is treated non-surgically in 90% of cases. 

It is not uncommon for multiple conditions to be present at the same time. If you experience shoulder pain, it is important to see a physician as soon as possible. In many of these conditions, early treatment can prevent larger issues in the future. Left untreated, less serious conditions can develop into more complicated issues that require surgical intervention and longer recovery times.

What is the Rotator Cuff?

The rotator cuff is a part of the shoulder that is necessary for stability and movement. The rotator cuff allows for lifting and rotation of the arm.  According to the American Academy of Orthopedic Surgeons, the rotator cuff sent approximately 2 million people to the doctor in 2008.[i]

Anatomy

The shoulder is a ball-and-socket joint made up of bones, muscles and tendons. The rotator cuff keeps the arm in the shoulder socket and is comprised of 4 muscles and tendons.

The three bones of the shoulder:

1. Humerus (upper arm bone)
2. Scapula (shoulder blade)
3. Clavicle (collarbone). T

The 4 muscles of the rotator cuff are:

1. Teres Minor
2.        Infraspinatus
3.        Supraspinatus
4.        Subscapularis.

The muscles of the rotator cuff attach to the scapula. Each muscle also has a tendon that attaches to the humerus. The tendons form a cuff around the shoulder joint, which provides stability for the shoulder joint and allows movement. Another important part of the shoulder is the bursa. The bursa is a sac that lies between the acromion (the upper bone in the shoulder) and the rotator cuff. The bursa allows the tendons to move easily.

Common injuries of the rotator cuff are tendonitis, bursitis and tears. Causes of injury include age, overuse or acute injury (fall on outstretched hand). Many conditions/injuries of the shoulder can be treated non-surgically, but more serious tears are typically treated with arthroscopic surgery.

In upcoming posts, we will discuss these injuries and conditions in more detail. If you feel that you have injured your rotator cuff, it is important to consult a physician. Advocare Orthopedic and Sports Medicine, the office of John Vitolo, MD is available to treat any orthopedic issues.

 

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[i] http://orthoinfo.aaos.org

Case Study: Biceps Tenodesis for Biceps Repair

A 52 year old male presented to our office for a second opinion after suffering a proximal biceps rupture at work. The patient had undergone a repair with another surgeon, but 8 days post-op he noticed that his biceps still looked deformed as it did before surgery.

Upon examination of the patient, we diagnosed him with a “Popeye Deformity”, a sagging deformity of the biceps. The previous surgeon had performed a bicipital groove repair, which did not repair the deformity. We discussed the options with the patient. We felt that a revision biceps tenodesis would be the best option. By performing this procedure, we could re-attach the biceps muscle at the proper length, eliminate the Popeye Deformity and restore function.

In this case, the surgical procedure selected involves a special technique referred to as the subpectoral biceps tenodesis (SPBT). In this specialized technique, the biceps is placed just beneath the pectoralis major tendon on the humerus. The procedure is performed using a small incision. The incision is placed at a discrete location near the inner fold of the arm pit.

SPBT was indicated in this case because of the failure of the previous surgery. Primarily, the SPBT guarantees that the biceps is brought back to its functional length. Also, in this procedure, the biceps is returned to its original anatomic state and will look and function in the same manner as the uninjured side. As an added benefit, cosmetically, the incision for the tenodesis is smaller and more discrete. A bicipital groove repair involves an incision in front of the shoulder and is a viable option in certain cases, but for some a biceps tenodesis yields better overall results.

SPBT is performed with a bio-absorbable anchor that will grow into the bone; metal anchors are never used in this repair. Recovery includes a sling for 4 weeks to protect the repair, followed by 6 to 8 weeks of physical therapy, which will help restore range of motion and strength. In this case, the patient recovered beautifully, is back to work and has regained the ability to perform all activities. When we spoke to the patient recently he stated that he has no pain or spasms, is back to working out at the gym every other day and is working hard at his autobody business. According to the patient, “I feel great and have no issues with my biceps.” A complete success in our opinion.

For more information or to schedule an appointment with John Vitolo, M.D., please call 973-300-1553, visit our website www.advocareorthosportsmed.com or follow us at facebook.com/johnvitolomd.

Case Study: Shoulder Biceps Tenodesis

A 58 year old male came into the office for a second opinion approximately one year after shoulder surgery in Florida. The previous surgery entailed “shaving” of a labral tear, but no evidence of repair. The labrum is soft, fibrous tissue that surrounds the shoulder joint. Despite the previous surgery, he continued to experience pain with overhead activities, was unable to lift and had trouble sleeping due to the pain. The pain was not relieved with cortisone injections. 

Our first goal was to determine the exact source of the patient’s pain. An MRI of his shoulder revealed a labral tear and damage to his biceps tendon. The biceps tendon is attached to the labrum, which is located between the ball and socket joint. Following injury, this biceps tendon can pull the labrum off the shoulder joint and create constant tension and pain. Once this tension is released by cutting the biceps tendon, the labrum returns to its normal position and pain is reduced. The biceps can then be placed in another anatomic location so that it will function properly and not cause pain.

 

We then performed an ultrasound guided biceps tendon sheath injection. If the injection provided relief, we would be able to confirm that pain was coming from the biceps tendon. The patient experienced relief from the pain after the injection; therefore our suspicion was confirmed.  

For treatment, opted to perform an outpatient shoulder arthroscopy and perform a biceps tenodesis.  In this procedure, the biceps tendon is released and then reattached arthroscopically. One week after surgery, the patient stated his pre-operative pain had significantly improved and he was sleeping well at night. He started physical therapy 3 weeks after surgery and wore a sling for 4 weeks to protect the repair. 9 weeks post-op, the patient stated his pain was absent, his range of motion was almost completely restored, and his strength was improving. He was discharged in excellent condition 15 weeks after surgery. 

Dr. Vitolo, who specializes in shoulder and knee arthroscopy, performs a unique arthroscopic biceps tenodesis. This arthroscopic procedure eliminates the need for a large incision, metal anchors, or significant soft tissue trauma. This arthroscopic biceps tenodesis is the latest advancement in shoulder arthroscopy performed by Dr. Vitolo for specific injuries. 

For more information on Dr. Vitolo and shoulder injuries, please visit http://www.advocareorthosportsmed.com or check us out on facebook: facebook.com/johnvitolomd.