Shoulder pain due to the rotator cuff is one of the most common complaints presenting to an orthopedic surgeon's office. Lucas Rylander, M.D., a physician with the Orthopedic Center of Illinois, provides the answers on when you need surgery? What happens if you don't have the tear repaired? Also, what does this mean for the long term?
Shoulder pain due to the rotator cuff is one of the most common complaints presenting to an orthopedic surgeon's office. Fortunately, most rotator cuff disease is really inflammation of the rotator cuff and surrounding tissue, not an actual tear. In most cases the inflammation will resolve with time, physical therapy, and injections. However, when a rotator cuff tear is found, much fear and trepidation occurs for patients. Do I need surgery? What happens if I don't have the tear repaired? What does this mean for me in the long term?
In order to answer these questions, one first needs to understand that the rotator cuff is really four different muscles/tendons grouped together. Collectively, these four muscles help to center the ball portion of the shoulder in the socket. Further, these muscles help to raise the arm and rotate it in and out. The most commonly inflamed or torn muscle is the supraspinatus. This muscle helps to raise the arm forward and out to the side; it also prevents the ball from floating upward within the socket. When you hear physicians talk about rotator cuff tears, this is the tendon being talked about most of the time.
Another important distinction is the difference between a full thickness tear and a partial thickness tear. When the rotator cuff tendon attaches to the bone, it attaches not at just one point but over an area about as long and as wide as one of your fingers. The length of a tear is variable and has nothing to do with the term partial or full thickness. These terms indicate the width of the tendon that is torn off of the bone. In full thickness tears, the full width of the tendon is torn off of the bone. In partial thickness tears, some of the width of the tendon is torn off of the bone: low grade partial tears involve less than 50 percent of the width while in high grade tears more than 50 percent is torn.
How does this impact you? When a tear is a low grade partial tear, it behaves much like an inflamed but not torn rotator cuff. When the tear is more high grade, it tends to behave much like a full thickness tear. While it is uncommon for these partial tears to re-heal to the bone, true healing is not necessary for shoulder function to return to normal in most cases. A partial thickness tear can become a full thickness tear, though this does not happen in all cases. If it does become a full tear, it is treated just like any other full tear, which I will address next.
So you have a full thickness rotator cuff tear. What now? The true answer is that there is not one "correct" answer, which can cause a lot of confusion for patients. Each case is truly unique, and who needs an operation must be decided on a patient by patient basis. There are some important things to know regarding how I help my patients make this decision.
First, is the tear really causing your pain? A few studies have used either an ultrasound or an MRI to look at the rotator cuff of asymptomatic volunteers. One such study found that 28 percent of people over the age of 60 had a full tear and didn't even know it. Between the ages of 40 and 60 this number dropped to 4 percent. Another similar study found more than 50 percent of patients over the age of 70 had either a partial or a full tear without any symptoms. How many of these patients may or may not develop pain over time is unknown. The moral of this story is that a trial of physical therapy and injections is often the best first intervention for patients over the age of 60. In these cases, the pain may be just acute inflammation occurring in the setting of a chronic tear; i.e., the tear may have already been present for a long time and just an incidental finding. This is especially true in cases of atraumatic shoulder pain, which is usually the rule as opposed to the exception. A well designed multicenter trial comparing the results of operative versus nonoperative rotator cuff tear treatment is under way. At this time the results are still unpublished, but early data has shown very favorable results with physical therapy alone for atraumatic tears in patients over 60.
A second factor in whether or not to have surgery is my patient's individual goals. A young patient who works overhead in construction is very different from a retired patient who only has to reach overhead to shower or reach into a cupboard. I am more likely to recommend an operation to the former patient than the later if therapy fails. Further, for patients that are simply scared to have surgery, have many other diseases that make surgery risky, or who cannot take the time to go through a postoperative recovery process, I would defer an operation. A rotator cuff tear is quite unlike appendicitis: a short delay prior to operating, if surgery is ever necessary, rarely has any long lasting ill effects.
A third factor in my operative decision making is the tear itself. Some large and retracted tears may not be possible to repair. Occasionally, in a shoulder that has not been used for a very long period of time, the muscle may be replaced by fat. In these very unusual cases, even if the tear is amenable to repair, the muscle can no longer work to move the shoulder: the engine can no longer move the piston. Also, if arthritis is present in the setting of a rotator cuff tear, a rotator cuff repair is unreliable in relieving pain, because the arthritis is still present. If a patient has any of these issues, even if he or she is quite young, I would start with conservative treatment first.
To conclude, the decision to operate on a rotator cuff tear must be tailored to each individual patient. My goal is to help a patient decide what will work best for him or her. In general, in a patient under the age of 40 with an acute and traumatic tear, operative intervention is often indicated. In patients over the age of 60 with a chronic, atraumatic tear (the most common presentation), I always recommend a trial of physical therapy and/or injections first. In fact, I find it quite rare for surgery to be my first treatment recommendation. When I do perform surgery, I favor minimally invasive rotator cuff repairs done arthroscopically, and generally tell patients they will be in a sling for six weeks after the operation, and recovery will take approximately six months.
Dr. Lucas Rylander is a physician with the Orthopedic Center Of Illinois.