Rotator Cuff Repair

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.

Shoulder Instability

The shoulder is the most frequently dislocated joint in the body. The ball and “flat” socket configuration of the joint allows the largest range of motion of any joint in the body but sacrifices stability. A shoulder dislocation occurs for 2 reasons: 1) from a traumatic injury that forces the ball out of its socket 2) from an inherent baseline laxity of the ligaments. On occasion, the shoulder slides back into place on its own. Most of the time the shoulder needs to be put back into place in the hospital with medication to help relax the muscles. Once the shoulder is back in place, patients are usually put into a sling for a couple of weeks to allow the shoulder to heal. At this point a physical therapy program can begin to restore range of motion and strength. Unfortunately, the torn tissue with the joint does not always heal enough to restore stability to the joint. Therefore, if someone dislocates their shoulder once, there is a good chance that it will happen again. This depends somewhat on age and activity. If a person less than 20 dislocates twice there is a >90% chance it will continue to dislocate. In these settings frequently surgery is chosen to restore stability.

Surgical treatment of a shoulder dislocation depends on what is injured in the shoulder. X-rays and an MRI are done to look for what is injured inside the joint. Surgery to fix the shoulder can be done arthroscopically through small incisions most of the time. Surgery is aimed at repairing the small bumper of tissue, called the labrum that tears off of the socket. The labrum is the structure that attaches the ligaments to the socket (glenoid). On occasion, an open surgery may need to be done to repair the labrum or to fix bone fragments that have broken off the socket to improve stability. If the bone on the socket wears away from repeated shoulder dislocations, bone from another part of the body may be needed to reconstruct the socket to make the shoulder stable again.

For patients with baseline loose ligaments due to stretchy collagen surgery may not be the first line of treatment. Due to their loose ligaments they are prone to stretch out surgical reconstructions so a long period of therapy is tried first before resorting to surgery.

After surgery, patients are placed in a sling to protect the shoulder for 4 weeks. Patients then begin a controlled physical therapy program and return to sports often takes 5-6 months. Arthroscopic surgery outcomes are usually successful 90% of the time with no further instability. Here at Washington University we are involved with a multi-center instability study as part of the MOON Shoulder Study Group to analyze predictors of successful shoulder stabilization surgery. Future blogs will look at additional issues regarding shoulder instability.