Understanding the Rotator Cuff
The rotator cuff is a collection of muscles which move your shoulder. The rotator cuff allows you to raise your arm over your head as well as reaching away from your body and towards your body. When the rotator cuff is injured, it can become inflamed or tear. Some tears do not go completely through the rotator cuff. If the tear is usually less than about 50% it usually does not have to be repaired and has some potential for healing. However, if it is torn more than about 50% repair of the rotator cuff is indicated. If the rotator cuff is torn all the way through and repair is usually indicated. In some cases, especially in elderly people, a torn rotator cuff does not have to be repaired if it is not sufficiently painful.
Partial Rotator Cuff Tears
Partial tears that are greater than 50% and sufficiently painful should be repaired if possible. Repair of a partial tear is easier to perform and usually is not associated with deterioration, or atrophy of the muscle. Many times, a partial tear will go on to a full-thickness tear. When a full-thickness tear occurs, the muscle can retract if the tear is large. When the muscle retracts the muscle fibers can scar over time and deteriorate. When this occurs, fat takes over where the muscle fibers have deteriorated. This is called atrophy. You can see this in a weightlifter who stops lifting weights and often his muscles will turn to fat. When fatty atrophy occurs in the muscles they cease to work well. Many times, if we repair a severely atrophied muscle the patient will not recover normal strength, in fact sometimes repairing the rotator cuff may help with the pain but not allow good return of function.
Full Rotator Cuff Tears
A full-thickness rotator cuff tear can involve just 1 or up to 3 or 4 tendons of the rotator cuff. The more muscles involved, the more severe the loss of function. Rotator cuff tears seemed to do best when repaired early after the injury before fatty atrophy of the muscle occurs. Best results seem to be if the shoulder is repaired within 3 months of the injury. Repair can be accomplished after that time period; but the repair can be much more difficult to achieve. In some cases, if too long a time has passed the rotator cuff becomes nonrepairable. The muscles retract and become scarred in the retracted position. Fatty atrophy sets in and the ability of the muscles to return to normal function becomes less predictable.
Chronic Rotator Cuff Tears
A chronic rotator cuff tear, or one that has been present for a long period of time, is difficult to repair and sometimes impossible to repair. To accomplish a repair on a retracted rotator cuff tear often requires the release of scar tissue to get the muscles out to length. In some cases, this can only be partially accomplished. This sometimes will leave a gap in the repair. To bridge the Gap in the repair we can use a graft either from local tissue such as your biceps tendon or graft prepared from donated skin or processed animal skin. The grafts that are preferred are those that are usually most like your own tissue. However, the grafts that are prepared from donated tissue or processed animal tissue are thoroughly cleaned and treated to prevent rejection. In that situation, your own tissue will grow into these grafts. Your own cells will grow into the fibrous tissue from the graft and use the graft as a template for reestablishing integrity of the tissue.
Some cases, the gap is too large, or arthritis has set in. If a rotator cuff tear has been present for a long period of time the ball of the shoulder, we call the humeral head, can migrate through the hole in the rotator cuff and rub on the bone that is above the shoulder joint. When that occurs, the cartilage can be worn off and severe arthritis can occur. When this occurs, it is called rotator cuff arthroplasty.
Is Shoulder Arthroplasty Needed?
If rotator cuff arthroplasty occurs, then any attempts at repair will be unlikely to have a satisfactory result. In those situations, a shoulder replacement is often indicated. A standard or anatomic total shoulder is a shoulder replacement that mimics normal anatomy. With rotator cuff arthroplasty or a severely deficient rotator cuff an anatomic total shoulder cannot be used with good results. In this situation, better function is obtained with what we call a reverse total shoulder. A reverse total shoulder puts the ball where the socket is in a normal shoulder and the socket is placed where the ball is normally located on the humerus. That is why it is called a reverse because the components seem to be backwards. The reverse total shoulder will make up for the lack of the rotator cuff by allowing the components to snap together.
Recommended Rotator Cuff Repair Treatments
We have many ways to treat rotator cuff injuries. In partial tears that are less than 50% many can be treated without surgery. For full-thickness tears, early repair as best. If treatment is delayed and scarring and atrophy occurs repair is more difficult but in many cases the repair can be accomplished sometimes with the use of a graft. In situations where the rotator cuff has been torn for a long period of time shoulder replacement may be required with a reverse total shoulder arthroplasty.
In healthy people, rotator cuff or shoulder surgery can usually be accomplished as an outpatient procedure. Even total shoulder arthroplasty can often be done as an outpatient procedure in healthy people. People with severe respiratory or cardiac disease usually are treated as inpatients so that they can be observed overnight to make sure they are healthy enough to return home without risk.
Request an Appointment
Schedule a Consultation with Dr. Miers Johnson, Orthopedic Specialist.