The rotator cuff consists of four muscles that surround the
ball and socket joint in the shoulder. Their
role is to initiate shoulder
movement and to stabilize the joint by compressing the ball against the socket
when larger muscles such as the deltoid, trapezius, and latissimus are
recruited to perform heavy lifting or overhead activities such as those in
tennis or baseball. Overuse and acute traumatic injuries can cause a tear in
one or more of the tendons that attach the rotator cuff muscles to the bone on
the ball of the shoulder. This is a common injury seen in orthopedic sports
medicine clinics. The patient that presents with a rotator cuff tear typically
will describe pain or inability to use their arm
away from their body. This
includes reaching overhead, reaching away from their body and reaching behind
the back. Physical examination will often demonstrate weakness in muscle
testing of the rotator cuff. X-rays are most often normal. An MRI or an ultrasound test can be used to determine if a rotator cuff tear is present.
Depending on the individual surgery or nonoperative
management may be an option. Chronic tears with a gradual onset can frequently
be managed by physical therapy as we demonstrated in our MOON Shoulder study
where 85% of patients over 50 years old with chronic tears were successfully
managed for a minimum of a year without surgery. Future blogs will discuss this study further, but it can be found here.
MOON Shoulder Study It appears that surgery is more routinely indicated in a couple of
circumstances: 1.) tears in individuals less than 50 years old and 2.) acute
tears with no previous history of a full thickness tear. This is somewhat
controversial and strict indications for rotator cuff repair are difficult to
tease out of the medical literature as Brian Wolf, Warren Dunn and I found when
we performed a review on the topic in the American Journal of Sports medicine.
Rotator Cuff Repair Indications
Surgical repair involves typically an arthroscopic approach
utilizing small puncture wounds where small minimally invasive instruments are
used to reattach the torn rotator cuff tendon. This is done by placing anchors
with sutures into the bone and stitching the tendon in place. Physical Therapy
begins shortly after surgery and continues 3-4 months until strength and motion
have been regained.
The role of the meniscus in
cushioning the joint and protecting the articular cartilage makes preserving
them a key part of knee health. For a meniscus tear unfortunately meniscectomy
(removing the torn portion) is the appropriate treatment 90% of the time. This
is because in most situations a repair will not be successful. The reasons
repair is not attempted is due to the lack of blood supply in 1/3-1/2 of the
meniscus that precludes healing of a repair. Additionally, if the configuration
of the tear is not appropriate then repair is not possible. In the 10% of
situations when repair is possible it is typically highly successful in the
short term with > 90% success without reoperation within the first 2 years.
Our ability to predict ahead of time whether or not repair will be possible has
been evaluated. In a study performed in conjunction with my partners and
published in the American Journal of Sports medicine we found we were able to
predict the chance to repair a meniscus 74% of the time. This makes it easier
to tell patients what to expect after surgery regarding recovery and
rehabilitation. Read the Abstract HERE.
We evaluated the MOON meniscus
repair results at 2 years in a study published in the American Journal of
Sports Medicine and found that in 82 tears of which we were able to obtain
follow up on 77 (94%) there was a success rate of 96% with no further surgery required
for the meniscus within the first 2 years following repair in 74 of the 77
repairs. Read the full study HERE. In future blogs I will discuss the longer
results we have noted at 5 years or more following meniscus repair.
