Arthroscopic shoulder surgery for the treatment of rotator cuff tears

Tears of the rotator cuff of the shoulder are potentially painful and disabling conditions, and the treatments for these conditions vary widely depending upon the severity of symptoms and signs. The person with a rotator cuff tear can have a sudden (acute/traumatic) or gradual (chronic) onset of shoulder pain with or without weakness. Although tears can occur as a result of a traumatic injury, many tears occur gradually and no specific injury can be recalled. The pain is usually located at the front and side of the shoulder or upper arm, and is frequently described as having a “aching”, “burning” or “toothachy” quality. The usually occurs with overhead motions, but can progress to the point that it is present with normal activities, or wake the patient during sleep.

While most people have heard of the “rotator cuff”, many are unclear about why we have one and how it functions. The term “rotator cuff” refers collectively to a group of four relatively small muscles that surround the “ball and socket” joint of the shoulder. These muscles are called the supraspinatus, infraspinatus, subscapularis and teres minor. One function of these muscles is to aid in the rotation of the arm around its long axis (as when one throws a Frisbee or passes a plate from side to side). Another, perhaps more important function of the rotator cuff is to keep the humeral head (the “ball” of the joint, connected to the arm) centered in the shallow glenoid (the “socket” of the joint, which attaches the arm to the body). When the larger muscles around the shoulder (the deltoids, pectoralis, latissimus, and others) move the arm, they tend to impart forces that act to displace the humeral head from the socket. The rotator cuff muscles must contract to keep the ball and socket joint centered. When the cuff muscles become weak, torn, or injured, they can no longer perform this centering function, and the abnormal motions affect the normal function of the shoulder. This usually causes pain and weakness with shoulder motion.

Many patients will improve with appropriate rehabilitation of the rotator cuff. However, some patients will have continued symptoms despite adequate rehabilitation and may require surgery. Arthroscopic shoulder surgery should be used to both define and diagnose the exact nature of the tears. In most cases, the problem can be treated using specially-designed instruments working through very small incisions with a minimum of discomfort and without the need for a hospital stay.

An experienced physician, therapist, shoulder surgeon or sports medicine surgeon can usually recognize the signs of rotator cuff problems. While the rotator cuff can not be directly visualized on X-rays, there may be subtle signs on the bones of the shoulder joint that can suggest a problem. If suspected, the diagnosis can almost always be made or confirmed using Magnetic Resonance Imaging techniques (MRI). However, many different problems can present with shoulder pain, so a thorough clinical examination by an experienced orthopedic shoulder surgeon is recommended. For many people, a conservative approach with formal physical therapy and then a home-based strengthening program can resolve the pain, weakness and disability of a rotator cuff tear. However, certain people may require surgery to regain normal, painless shoulder function:

• Persons whose symptoms do not improve with appropriate physical therapy or rehabilitation

• High-demand athletes after an acute injury

• Overhead workers or laborers

• Persons who have changes on X-ray or MRI that suggest that irrecoverable damage to the shoulder may occur if the shoulder mechanics are affected by the cuff tear.

Arthroscopic shoulder surgery, or shoulder arthroscopy is a valuable tool to treat rotator cuff tears. Using the scope, an experienced surgeon who is facile with arthroscopic techniques can evaluate the entire shoulder joint and can usually fix the tear through very small incisions using specially-designed instruments and devices. It is a common misconception that tears that are large should not be repaired arthroscopically—in fact the advantages of visualization and complete access to the tear make such large tears particularly amenable to arthroscopic repair. The goals of repair are to restore normal and painless motion and full strength to the affected shoulder:

the rotator cuff tear is identified and loose, degenerated, and frayed tissue around the cuff edge must be removed back to healthy tissue. This process is called débridement.
The edge of the cuff tear must be brought back to its normal position without undue tension. This process is accomplished using techniques called mobilization or in larger tears, a technique called margin convergence.
The tear must be fixed into place using specially-designed suture anchors that allow the surgeon to approximate the cuff tear securely to the bone.

The results are most predictable in the hands of a highly-specialized surgical team that is familiar with the various techniques and instruments and who perform this surgery often. Such a team will maximize the benefits of the surgery and minimize the risks. The procedure can usually be performed within a few hours under general (or nerve block) anaesthesia, and the patient can be discharged to home with a minimum of discomfort. In addition, the scope allows the surgeon to take pictures and video to show to the patient what problem(s) existed and how the problem was addressed.

Patients undergoing arthroscopic rotator cuff repair still require a limited period in a sling (usually 4- to 6-weeks) with some simple range-of-motion exercises at home. They will require fairly intensive outpatient physical therapy for re-establishing pain-free motion and strengthening the shoulder muscles for a few months. Normally, a person can return to most forms of normal activity within 6 to 8 weeks, and limited athletics between 12 and 16 weeks.

Incidence and risk factors

It is difficult to estimate the number of persons who have injury to the rotator cuff, because even full-thickness tears may not necessarily affect function. However, painful or symptomatic rotator cuff tears are a common cause of shoulder pain. They can occur in young or old persons, with or without a traumatic injury, and in active and sedentary populations alike.

Risk factors for a rotator cuff tear include:

overhead athletes or laborers
traumatic injuries or dislocations of the shoulder joint
those who perform repetitive overhead activities
contact athletes (football, hockey, wrestling, lacrosse)
persons who have had a rotator cuff tear on the opposite shoulder

Diagnosis

A physician can diagnose rotator cuff injury by reviewing the patients history, performing a thorough physical examination and shoulder examination, and through the use of imaging techniques such as X-rays and magnetic resonance imaging (MRI).

The physical examination and history are a reliable means to diagnose rotator cuff weakness and pain. Many times, persons will have no abnormalities on X-ray (the cuff can not be visualized with x-ray), but MRI is very reliable in confirming a suspected diagnosis. Frequently, and MRI arthrogram will be performed. For this study, a contrast ‘dye’ is injected into the joint just prior to the MRI. This study is nearly 100% accurate in diagnosing a tear.

X-rays may show bony injuries reactions to a dysfunctional rotator cuff tear. Cysts can occasionally be visualized in the region of the cuff insertion at the humerus, the humeral head may migrate toward acromial roof, or bone spurs may develop on the undersurface of this roof. MRI images give cross-sectional pictures of the rotator cuff. Small tears or fraying of the cuff tissue are frequently seen, and large and massive tears are easily appreciated.

Treatments

Medications

Because cuff tears are an essentially mechanical problem, there are no medications that can “cause” the cuff to heal spontaneously. However, some medications such as Non-steroidal Anti-inflammatory Drugs (NSAID’s) will frequently help to ease the pain and symptoms related to the torn cuff. These medications can be quite helpful, but can also have side effects and therefore should be taken under the supervision of a physician experienced in their use. Injections of steroids (cortisone) into the shoulder will occasionally be recommended to ease the symptoms of inflammation in the shoulder while a physical therapy program is initiated to rehabilitate the rotator cuff muscles and restore function. While the effects of the cortisone are not permanent, if the cuff can be strengthened while the cortisone is helping ease inflammation, the symptoms may not return as the mechanics of the shoulder are restored.

For any medications taken, patients should learn:

the risks, possible interactions with other drugs
the recommended dosage
the cost

Possible benefits of arthroscopic rotator cuff repair and shoulder surgery

In persons who continue to have symptoms despite an adequate trial of physical therapy, surgical repair of the rotator cuff is the most effective method to restore strength and eliminate pain.

Different shoulder surgeons have different preferences regarding how they like to repair torn cuff tissues. One of the obstacles to surgery of the shoulder (unlike the knee) is that the shoulder is surrounded by a bony and muscular “envelope”. The shoulder blade, or scapula acromion. The rotator cuff muscles originate on the scapula, and surround the socket and humeral head under this acromial roof. The larger deltoid muscles originate from the surface of the acromion, and form another muscular barrier to the cuff as well. In short, the rotator cuff is “protected” in the front, side and back by the deltoid muscles, and is inaccessible from the top owing to the bony acromion. forms the bony glenoid socket of the joint, and also forms a bony “roof” over the humeral head called the

Historically, surgeons had to make large incisions in the skin and split and move the deltoid muscles to gain access to the rotator cuff. Serious and debilitating complications developed if the deltoid muscle origin did not heal back to the acromion, so surgeons now will now access the rotator cuff tear by leaving the deltoid muscle attached and simply splitting it (like ‘peeking through closed curtains’) to gain access to the rotator cuff where it attaches to the humerus. This process is ideal for tears that have not pulled back, or retracted back away from the deltoid. However, in cases of larger retracted rotator cuff tears, working through a deltoid split can become a little like building a ship in a bottle—trying to work through the narrow mouth of a bottleneck to get to the retracted cuff tissue.

With the advent of arthroscopy, innovative shoulder surgeons found that one could make a few very small incisions in the skin and deltoid muscles surrounding the shoulder joint and could have access to every part of the rotator cuff. These incisions are small enough that they do not affect the function of the deltoid muscle or injure its origin on the acromion. Using the arthroscope and instruments specifically designed for the purpose of manipulating and repairing the tissue, the surgeon can work from any angle around the tissue. The techniques and skills required for an all-arthroscopic rotator cuff repair are relatively new, however, and require special training and a dedicated and skilled operating team.

Who should consider arthroscopic rotator cuff repair and shoulder surgery?

Arthroscopic shoulder surgery is considered for cuff tears when:

pain, weakness, and disability represent a significant problem for the patient, and inhibit his or her ability to perform the activities of daily living, overhead activities, or sporting activities
the patient is sufficiently healthy to undergo the procedure
an appropriate and comprehensive diagnostic evaluation has been performed and the nature of the problem is clear
the surgeon is experienced and familiar with several techniques and treatments for shoulder injuries, including arthroscopic surgery.
the patient is capable and willing to undergo a comprehensive post-operative rehabilitation (physical therapy) program
the patient does not gain financially from remaining disabled or injured (e.g. lawsuits, disability)

The results of arthroscopic rotator cuff repair procedures are most effective when the patient follows a simple post-operative rehabilitation program. Thus, the patient’s motivation and dedication are important elements of the partnership.

What happens without surgery?

Persons who suffer from pain, weakness and muscular imbalances in the shoulder may lose valuable time from work, become progressively disabled, or worse: do permanent or irreparable damage to the rotator cuff or develop premature arthritis.

It is impossible to predict whether a person who first presents with short-term pain and disability from a rotator cuff injury or tear will improve without surgery. Except in rare instances, an experienced physician or surgeon will first try to rehabilitate the shoulder with an intensive physical therapy program. If the function of the rotator cuff can be balanced, many people will avoid the need for surgery.

In cases of an extremely long-standing rotator cuff tear with shoulder dysfunction, arthritis can occur in the shoulder joint. This process is called rotator cuff arthropathy and can lead to severe disability and irreversible changes to the shoulder joint. Usually, if the process has gone unchecked for a long time, a rotator cuff repair is unlikely to be successful. Other surgical operations, involving replacement of the humeral head (also called hemi-arthroplasty) may be required to alleviate symptoms.

Surgical options

In the hands of a surgeon who is experienced with arthroscopic shoulder surgery, almost all of the following procedures can be performed alone or together to restore strength and eliminate pain in the shoulder joint or from the rotator cuff:

repair of the rotator cuff
repair of the biceps tendon or anchor
removal of “bone spurs” from the undersurface of the acromial roof (subacromial decompression)

Effectiveness

In the hands of an experienced surgeon, arthroscopic rotator cuff repair can be very effective in eliminating pain and restoring strength and function to the shoulder of a well-motivated patient. The greatest benefits are often the ability to perform the usual activities of daily living, overhead activities, and sports without discomfort, and to sleep without a chronic ache in the shoulder. As long as the shoulder is cared for properly and subsequent traumatic injuries are avoided, the benefits of repair should be permanent.

Preparation

Surgical rotator cuff repair is considered for individuals whom pain and weakness interfere with shoulder function and activity.

Successful surgery depends upon a partnership between the patient and the experienced shoulder surgeon. Patients should optimize their health to prepare for surgery. Smoking should be stopped one month prior to surgery, and be avoided altogether for at least three months following surgery. Any heart, lung, kidney, bladder, tooth, or gum problems should be managed before the shoulder surgery. Any active infections will delay elective surgery to optimize the benefit and reduce the risk of shoulder joint infection. The surgeon should be made aware of any health issues, including allergies and non-prescription and prescription medications being taken. Some medications will need to be held or stopped prior to surgery. For instance, aspirin and anti-inflammatory medications should be discontinued as they will affect intraoperative and postoperative bleeding.

Patients must recognize that the procedure is a process and not an event: the benefits of the surgery depend a large part on the patient’s willingness to apply effort to rehabilitation after surgery.

Patients must plan on being less active and functional for 12 to 16 weeks after the surgery. Driving, shopping and performing overhead chores, lifting, and repetitive arm activities may be difficult or impossible during this time. Plans for the necessary assistance need to be made before surgery. For individuals who live alone or those without readily-available help, arrangements for home help should be made well in advance.

Anesthetic

Arthroscopic shoulder stabilization procedures may be performed under a general anesthetic or under a regional block that makes the shoulder and arm numb during and for several hours after the procedure. The patient may wish to discuss their preferences with the anesthesiologist prior to surgery.

Length of arthroscopic rotator cuff repair and shoulder surgery

The procedure takes approximately 2 to 2 ½ hours, however, the preoperative preparation and postoperative recovery can easily double this time. Patients usually spend 1 or 2 hours in the recovery room. Patients who undergo arthroscopic procedures almost always are comfortable enough to be discharged home. Those undergoing more traditional open procedures may require one night’s hospitalization.

Use of medications

Immediately postoperatively, pain medications are given through an intravenous (IV) line. Patients who require a hospital stay are placed on patient controlled anesthesia (PCA) to allow them to administer their own medication as it is needed. Oral pain medications are rarely required after the first two to three weeks following the procedure.

Effectiveness of medications

Pain medications are very powerful and effective. Their proper use lies in the balancing of their pain-relieving effect and their other, less desirable effects. Good pain control is an important part of appropriate postoperative management.

Hospital stay

Most patients will not require a hospital stay after an arthroscopic rotator cuff repair procedure. Generally, a person must spend an hour or two in the recovery room until the anesthetic medication has worn off. The instructions for the care of their shoulder, bathing, use of medications, and potential problems are explained to the patient and their family prior to discharge.

Recovery and rehabilitation in the hospital

When the patient is ready for discharge they will be explained:

What home exercises are appropriate and how often to do them
How to take their medications
When and how to remove the postoperative dressing
How to use their postoperative sling
How to care for their shoulder and incisions
How to recognize potential problems, and what is normal and abnormal
Who to call if there is a question

Because fluid is used to expand the shoulder joint during arthroscopic procedures, the shoulder is frequently swollen for a few days following surgery. Also, the incisions will “weep” fluid for a couple of days postoperatively, and the dressing can become damp.

The patient is asked to refrain from using the shoulder and arm for any overhead activities EVEN IF IT FEELS GOOD for 3 to 4 weeks after the procedure and remove the sling only to perform a strict set of limited exercises of the wrist, elbow and shoulder. These exercises will be explained prior to discharge.

Some patients find that finding a comfortable position to sleep can be difficult for the first few days. Some tricks to help sleeping are to:

Try sleeping in a semi-reclined position or recliner chair
When lying down, support the elbow from behind with one or two pillows so it doesn’t fall back against the bed
The patient should not sleep on their side or stomach

For the first 3 or 4 weeks, a home program of rest and limited self-therapy is usually recommended. Then, as healing has progressed, the arm is removed from the sling and a formal rehabilitation program is started with the physical therapist, on an outpatient basis.

Physical therapy

Some early motion is important after rotator cuff repair, but unrestricted motion can endanger the success of the procedure. For the first 3 or 4 weeks, the patient is scheduled to see a physical therapist once or twice per week to monitor the progress of healing and to reiterate the proper exercises.

After a few weeks, the sling is removed, and a more comprehensive rehabilitation program is started. During this period, the therapist works closely with the patient to re-establish a normal range of motion. The therapist and patient work together, but the patient is expected to do “homework” on a daily basis so that constant improvement is achieved. Once a normal range of motion is re-established, shoulder strengthening is started. It takes about 12-16 weeks before the shoulder is completely rehabilitated for the normal activities of daily living, and about 4-6 months before contact athletics, throwing, and overhead sports can be re-started. Therapist can work with the patient on “sports-specific” training to retrain the muscles and shoulder for golf, tennis, throwing, and swimming.

Rehabilitation options

The results of physical therapy are optimized by a competent therapist, familiar with the procedure and the usual expectations, and a compliant patient, who is responsible to do home exercises and is motivated to improve. Surgeon has a standard “protocol” that they give to a physical therapist to let them know how to rehabilitate the shoulder. It is important for a patient to find a therapist with flexible hours and in a convenient location because the therapy will become part of a routine for 3 to 4 months. The surgeon can recommend a therapist or therapy group with whom he or she is used to working and who is familiar with the procedure. Therapy is generally done on an outpatient basis, with 2 or 3 visits per week so that the therapist can check the progress and review or modify the program as needed to suit the individual.

Usual response

Patients are almost always satisfied with the range of motion, comfort and function that they achieve as the rehabilitation program progresses. The sense of pain with overhead motions is usually present for several weeks following the surgery and is normal in the course of healing. Occasionally, persons will have slight decreases in their overall overhead mobility. These minimal decreases usually do not affect the ability to perform overhead activities or prohibit a return to athletics at the same or a higher level.

If the exercises remain or become painful, difficult, or uncomfortable, the patient should contact the therapist and surgeon promptly.

Duration of rehabilitation

Every patient is slightly different. Once the range of motion is acceptable and the strength has returned, the exercise program can be cut back to a minimal level. Patients who have special needs, such as overhead athletes, swimmers, overhead laborers, and throwers may require sports-specific training with a therapist or athletic trainer.

Returning to ordinary daily activities

In general , patients are able to perform gentle activities of daily living with the operated arm at the side starting 3 to 6 weeks after surgery. Most persons who work at a desk job can return to work during this time. The patient is strongly encouraged to continue wearing the sling at all times for the first 3 to 4 weeks to remind themselves (and others) that the shoulder is injured and healing, and to limit overhead activities.

Driving should wait until the patient can perform the necessary functions comfortably and confidently, and the pain in the shoulder is at a minimum and pain medications are not required. A good question to ask a patient is “Would you want you driving if your 4-year old child was in the car or playing in the street?”

With the consent of their surgeon, a patient may return to activities such as swimming, golf and tennis between 4 and 6 months following the procedure. More extreme sports (wrestling, pitching, rock climbing, etc) should only be undertaken when the shoulder is extremely comfortable, and the strength is within 90% of the opposite side.

Patient limitations till strength is regained

Patients must avoid impact activities (chopping wood, contact sports, sports with risk of falls) and heavy lifting (overhead labor, lifting heavy weights) until after the strength has returned to normal.