CENTER FOR SPORTS INJURY
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Your shoulder is the most flexible joint in your body. It allows you to place and rotate your arm in many positions in front, above, to the side, and behind your body. This flexibility also makes your shoulder susceptible to instability and injury.

Depending on the nature of the problem, non surgical methods of treatment often are recommended before surgery. However, in some instances, delaying the surgical repair of a shoulder can increase the likelihood that the problem will be more difficult to treat later. Early, correct diagnosis and treatment of shoulder problems can make a significant difference in the long run.

How the Normal Shoulder Works

The shoulder is a ball-and-socket joint. It is made up of three bones: the upper arm bone (humerus), shoulder blade (scapula) and collarbone (clavicle).

The ball at the top end of the arm bone fits into the small socket (glenoid) of the shoulder blade to form the shoulder joint (glenohumeral joint).

The socket of the glenoid is surrounded by a soft-tissue rim (labrum).

A smooth, durable surface (articular cartilage) on the head of the arm bone, and a thin inner lining (synovium) of the joint allows the smooth motion of the shoulder joint.

The upper part of the shoulder blade (acromion) projects over the shoulder joint. One end of the collarbone is joined with the shoulder blade by the acromioclavicular (AC) joint. The other end of the collarbone is joined with the breastbone (sternum) by the sternoclavicular joint.

The joint capsule is a thin sheet of fibers that surrounds the shoulder joint. The capsule allows a wide range of motion, yet provides stability.

The rotator cuff is a group of muscles and tendons that attach your upper arm to your shoulder blade. The rotator cuff covers the shoulder joint and joint capsule.

The muscles attached to the rotator cuff enable you to lift your arm, reach overhead, and take part in activities such as throwing or swimming.

A sac-like membrane (bursa) between the rotator cuff and the shoulder blade cushions and helps lubricate the motion between these two structures.

Shoulder Problems and Treatments

Bursitis or Tendinitis

Bursitis or tendinitis can occur with overuse from repetitive activities, such as swimming, painting, or weight lifting. These activities cause rubbing or squeezing (impingement) of the rotator cuff under the acromion and in the acromioclavicular joint. Initially, these problems are treated by modifying the activity which causes the symptoms of pain and with a rehabilitation program for the shoulder.

Impingement and Partial Rotator Cuff Tears

Partial thickness rotator cuff tears can be associated with chronic inflammation and the development of spurs on the underside of the acromion or the acromioclavicular joint.

The conservative nonsurgical treatment is modification of activity, light exercise, and, occasionally, a cortisone injection. Nonsurgical treatment is successful in a majority of cases. If it is not successful, surgery often is needed to remove the spurs on the underside of the acromion and to repair the rotator cuff.

Full-Thickness Rotator Cuff Tears

Full-thickness rotator cuff tears are most often the result of impingement, partial thickness rotator cuff tears, heavy lifting, or falls. Nonsurgical treatment with modification of activity is successful in a majority of cases.

If pain continues, surgery may be needed to repair full- thickness rotator cuff tears. Arthroscopic techniques allow shaving of spurs, evaluation of the rotator cuff, and repair of some tears.

Both techniques require extensive rehabilitation to restore the function of the shoulder.

Instability

Instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of sudden injury or from overuse of the shoulder ligaments.

The two basic forms of shoulder instability are subluxations and dislocations. A subluxation is a partial or incomplete dislocation. If the shoulder is partially out of the shoulder socket, it eventually may dislocate. Even a minor injury may push the arm bone out of its socket. A dislocation is when the head of the arm bone slips out of the shoulder socket. Some patients have chronic instability. Shoulder dislocations may occur repeatedly.

Patients with repeat dislocation usually require surgery. Open surgical repair may require a short stay in the hospital. Arthroscopic surgical repair is often done on an outpatient basis. Following either procedure, extensive rehabilitation, often including physical therapy, is necessary for healing.

Fractured Collarbone and Acromioclavicular Joint Separation

A fractured collarbone and acromioclavicular separation are common injuries of children and others who fall on the side of their shoulder when playing. Most of these injuries are treated non surgically with slings or splints. Severe displaced fractures or acromioclavicular joint separation may require surgical repair.

Fractured Head of the Humerus (Arm Bone), or Proximal Humerus Fracture

A fractured head of the humerus is a common result of falls on an outstretched arm, particularly by older people with osteoporosis. If fragmented or displaced, it may require open surgical repair and possibly replacement with an artificial joint (prosthesis).

Osteoarthritis and Rheumatoid Arthritis

Osteoarthritis and rheumatoid arthritis can destroy the shoulder joint and surrounding tissue. They can also cause degeneration and tearing of the capsule or the rotator cuff. Osteoarthritis occurs when the articular surface of the joint wears thin. Rheumatoid arthritis is associated with chronic inflammation of the synovium lining which can produce chemicals that eventually destroy the inner lining of the joint, including the articular surface.

Shoulder replacement

Shoulder replacement is recommended for patients with painful shoulders and limited motion. The treatment options are either replacement of the head of the bone or replacement of the entire socket .

Orthopaedic Evaluation

The orthopaedic evaluation of your shoulder consists of three components:

  • A medical history to gather information about current complaints; duration of symptoms, pain and limitations; injuries; and past treatment with medications or surgery.
  • A physical examination to assess swelling, tenderness, range of motion, strength or weakness, instability, and/or deformity of the shoulder.
  • Diagnostic tests, such as X-rays taken with the shoulder in various positions. Magnetic resonance imaging (MRI) may be helpful in assessing soft tissues in the shoulder. Computed tomography (CT) scan may be used to evaluate the bony parts of the shoulder.

We will review the results of your evaluation with you and discuss the best treatment. If surgery is the best option , you will be explained the benefits vs potential risks and complications .

Preparing for Surgery
  • No food or drink after midnight before surgery.
  • Discuss with us what to do about medications taken in the morning.
  • Pre-anaesthetic check up prior to the surgery .
Types of Surgical Procedures

You may be given the option to have an arthroscopic procedure or an open surgical procedure.

Arthroscopy

Arthroscopy allows us to insert a pencil-thin device with a small lens and lighting system into tiny incisions to look inside the joint. The images inside the joint are relayed to a TV monitor, allowing us to make a diagnosis. Other surgical instruments can be inserted to make repairs, based on what is with the arthroscope. Arthroscopy often can be done on an outpatient basis.

Open Surgery

Open surgery may be necessary and, in some cases, may be associated with better results than arthroscopy. Open surgery often can be done through small incisions of just a few inches.

Recovery and rehabilitation is related to the type of surgery performed inside the shoulder, rather than whether there was an arthroscopic or open surgical procedure.

Possible Complications After Surgery

There are always some risks with any surgery, even arthroscopic procedures. These include possible infection, and damage to surrounding nerves and blood vessels. However, modern surgical techniques and close monitoring have significantly minimized the occurrence of these problems.

After surgery, some pain, tenderness, and stiffness are normal. You should be alert for certain signs and symptoms that may suggest the development of complications.

  • Fever after the second day following surgery
  • Increasing pain or swelling
  • Redness, warmth, or tenderness which may suggest a wound infection
  • Unusual bleeding (some surgical wound drainage is normal and, in fact, desirable
  • Numbness or tingling of the arm or hand
Prevention of Future Problems & Summary

As you can see, the shoulder is extremely complex, with a design that provides maximum mobility and range of motion. Besides big lifting jobs, the shoulder joint is also responsible for getting the hand in the right position for any function. When you realize all the different ways and positions we use our hands every day, it is easy to understand how hard daily life can be when the shoulder isn't working well.

It is important that you continue a shoulder exercise program with daily stretching and strengthening. In general, patients who faithfully comply with the therapies and exercises prescribed by the physical therapist will have the best medical outcome after surgery.

Dislocating Shoulder
Introduction

Shoulder instability means that the shoulder joint is too loose and is able to slide around too much in the socket. In some cases, the unstable shoulder actually slips out of the socket. If the shoulder slips completely out of the socket, it has become dislocated. If not treated, instability can lead to arthritis of the shoulder joint.

What parts of the shoulder are involved?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone,) and the clavicle (collarbone).

The rotator cuff connects the humerus to the scapula. The rotator cuff is actually made up of the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move bones by pulling on tendons. The muscles of the rotator cuff also keep the humerus tightly in the socket. A part of the scapula, called the glenoid, makes up the socket of the shoulder. The glenoid is very shallow and flat. A rim of soft tissue, called the labrum, surrounds the edge of the glenoid, making the socket more like a cup. The labrum turns the flat surface of the glenoid into a deeper socket that molds to fit the head of the humerus.

Surrounding the shoulder joint is a watertight sac called the joint capsule. The joint capsule holds fluids that lubricate the joint. The walls of the joint capsule are made up of ligaments. Ligaments are soft connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack, loose tissue, so that the shoulder is unrestricted as it moves through its large range of motion. If the shoulder moves too far, the ligaments become tight and stop any further motion, sort of like a dog coming to the end of its leash.

Dislocations happen when a force overcomes the strength of the rotator cuff muscles and the ligaments of the shoulder. Nearly all dislocations are anterior dislocations, meaning that the humerus slips out of the front of the glenoid. Only three percent of dislocations are posterior dislocations, or out the back.

Sometimes the shoulder does not come completely out of the socket. It slips only partially out and then returns to its normal position. This is called subluxation

What makes a shoulder unstable?

Shoulder instability often follows an injury that caused the shoulder to dislocate. This initial injury is usually fairly significant, and the shoulder must be reduced. To reduce a shoulder means it must be manually put back into the socket. The shoulder may seem to return to normal, but the joint often remains unstable. The ligaments that hold the shoulder in the socket, along with the labrum (the cartilage rim around the glenoid), may have become stretched or torn. This makes them too loose to keep the shoulder in the socket when it moves in certain positions. An unstable shoulder can result in repeated episodes of dislocation, even during normal activities. Instability can also follow less severe shoulder injuries.

In some cases, shoulder instability can happen without a previous dislocation. People who do repeated shoulder motions may gradually stretch out the joint capsule. This is especially common in athletes such as baseball pitchers, volleyball players, and swimmers. If the joint capsule gets stretched out and the shoulder muscles become weak, the ball of the humerus begins to slip around too much within the shoulder. Eventually this can cause irritation and pain in the shoulder.

A genetic problem with the connective tissues of the body can lead to ligaments that are too elastic. When ligaments stretch too easily, they may not be able to hold the joints in place. All the joints of the body may be too loose. Some joints, such as the shoulder, may be easily dislocated. People with this condition are sometimes referred to as double-jointed.

What problems does an unstable shoulder cause?

Chronic instability causes several symptoms. Frequent subluxation is one. In subluxation, the shoulder may slip (sublux) in certain positions, and the shoulder may actually feel loose. This commonly happens when the hand is raised above the head, for example while throwing. Subluxation of the shoulder usually causes a quick feeling of pain, like something is slipping or pinching in the shoulder. Over time, you may stop using the shoulder in ways that cause subluxation.

The shoulder may become so loose that it starts to dislocate frequently. This can be a real problem, especially if you can't get it back in the socket and must go to the emergency room every time. A shoulder dislocation is usually very obvious. The injury is very painful, and the shoulder looks abnormal. Any attempted shoulder movements cause extreme pain. A dislocated shoulder can damage the nerves around the shoulder joint.

Once a labral tear develops , symptoms include

  • Pain, usually with overhead activities
  • Catching, locking, popping, or grinding
  • Occasional night pain or pain with daily activities
  • A sense of instability in the shoulder
  • Decreased range of motion
  • Loss of strength
Diagnosis

The diagnosis of shoulder instability is primarily done through your medical history and physical exam. The medical history will include many questions about past shoulder injuries, your pain, and the ways your symptoms are affecting your activities.

In the physical exam, we will feel and move your shoulder, checking it for strength and mobility. We will stress the shoulder to test the ligaments. When the shoulder is stretched in certain directions, you may get the feeling that the shoulder is going to dislocate. This is a very important sign of instability. It is called an apprehension sign. (Don't worry. Unless your shoulder is extremely loose, it will not dislocate.)

You will have an X-ray. X-rays can help confirm that your shoulder was dislocated or injured in the past.

If your diagnosis is unsure , an MRI Scan is helpful. Finally an examination under anaesthesia ( EUA ) is done followed by a shoulder arthroscopy . An arthroscope is a tiny TV camera inserted into the shoulder through a small incision. This allows a good look at the muscles and ligaments of the shoulder. When you are awake, it is hard to test the ligaments because you automatically tighten the muscles during the exam.

When you come with an acutely dislocated shoulder, X-rays are necessary to rule out a fracture. X-rays are usually done after the shoulder is put back into joint. This allows us to make sure the joint is back in place.

What treatment options are available?
Non surgical treatment

The first goal will be to help you control your pain and inflammation. Initial treatment to control pain is usually rest and anti-inflammatory medication . You may need a cortisone injection if you have trouble getting your pain under control. Cortisone is a strong anti-inflammatory medication.

The physical therapist will direct your rehabilitation program. At first, patients are shown ways to avoid positions and activities that put the shoulder at further risk of injury or dislocation. Overhand athletes may be issued a special shoulder strap or sleeve to stop the shoulder from moving in ways that strain it.

The therapist may use heat or ice treatments to ease pain and inflammation. Hands-on treatments and various types of exercises are used to improve the range of motion in your shoulder and nearby joints and muscles. Later, you will do strengthening exercises to improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This will improve the stability of the shoulder and help your shoulder joint move smoothly.

You may need therapy treatments for six to eight weeks. Most patients are able to get back to their activities with full use of their arm within this amount of time.

Surgery

If your therapy program doesn't stabilize your shoulder after a period of time, you may need surgery. There are many different types of shoulder operations to stabilize the shoulder. Almost all of these operations attempt to tighten the ligaments that are loose. The loose ligaments are usually along the front or bottom part of the shoulder capsule.

Bankart Repair

The most common method for surgically stabilizing a shoulder that is prone to anterior dislocations is the Bankart repair. The Bankart repair involves sewing or stapling ligaments, along with the labrum, on the front side of the joint back into their original position.

In a Bankart repair, we first clear away any frayed or torn edges. Holes for the sutures are drilled into the scapula bone. The capsular ligaments and labrum are then attached with sutures to the bone. The ligaments heal, and scar tissue eventually anchors the ends to the bone. With the ligaments back in place, the joint is much more stable.

Typically the Bankart repair is done through an incision on the front of the shoulder. We are doing it Arthroscopically in selected cases . Arthroscopes require smaller incisions, which means less time in the hospital and less time to heal.

Capsular Shift

Another surgery to tighten a loose shoulder joint is a procedure called a capsular shift. In this procedure, an incision is made on the front of the joint capsule to create a flap. The flap of tissue is pulled over the front of the capsule and sewn together. This is similar to when a tailor tucks loose fabric by overlapping and sewing the two parts together.

Thermal Capsular Shrinkage

There is a newer procedure called thermal capsular shrinkage. Using an arthroscope, we slides an electrode probe inside the unstable shoulder. The electrode is heated up, and we move the probe over the injured ligament. The heat causes the capsule to shrink and tighten. One of the risks with this type of surgery is that the capsule may get too tight, leading to restricted shoulder motion.

Rehabilitation
Non-surgical rehabilitation

The goal of therapy will be to strengthen the rotator cuff and shoulder blade muscles to make the shoulder more stable. At first you will do exercises with a therapist. Eventually you will be put on a home program of exercise to keep the muscles strong and flexible. This should help you avoid future problems.

After Surgery

Rehabilitation after surgery is more complex. You will likely wear a sling to support and protect the shoulder for one to four weeks. A physical or occupational therapist may direct your recovery program. Depending on the surgical procedure, you will probably need to attend therapy sessions for two to four months. You should expect full recovery to take up to six months.

The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy after Bankart surgery proceeds slowly. Range-of-motion exercises begin soon after surgery, but therapists are cautious about doing stretches on the front part of the capsule for the first six to eight weeks. The program gradually works into active stretching and strengthening.

Therapy goes even slower after surgeries where the front shoulder muscles have been cut. Exercises begin with passive movements. During passive exercises, your shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts three to four weeks after surgery. You use your own muscle power in active range-of-motion exercises. You may begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues.

At about six weeks you start doing more active strengthening. Exercises focus on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This helps your shoulder move smoothly during all your activities.

By about the tenth week, you will start more active strengthening. These exercises focus on improving strength and control of the rotator cuff muscles. Strong rotator cuff muscles help hold the ball of the humerus tightly in the glenoid to improve shoulder stability.

Overhand athletes (such as those who throw baseballs or footballs) start gradually in their sport activity about three months after surgery. They can usually return to competition within four to six months.

Some of the exercises you'll do are designed to get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Rotator Cuff Tears

Rotator cuff tears are a common source of shoulder pain. The incidence of rotator cuff damage increases with age and is most frequently caused by degeneration of the tendon, rather than injury from sports or trauma.

Anatomy

The rotator cuff is a group of four muscles that surround the humeral head (ball of the shoulder joint). The muscles are referred to as the "SITS" muscles: supraspinatus, infraspinatus, teres minor, and subcapularis. The muscles function to provide rotation, elevate the arm, and give stability to the shoulder joint (glenohumeral joint). The supraspinatus is most frequently involved in degenerative tears of the rotator cuff. More than one tendon can be involved. There is a bursa (sac) between the rotator cuff and acromion that allows the muscles to glide freely when moving. When rotator cuff tendons are injured or damaged, this bursa often becomes inflamed and painful.

Pain, loss of motion, and weakness may occur when one of the rotator cuff tendons tears. The tendons generally tear off at their insertion (attachment) onto the humeral head.

Cause

The rotator cuff can be torn from a single traumatic injury. Patients often report recurrent shoulder pain for several months and a specific injury that triggered the onset of the pain. A cuff tear may also happen at the same time as another injury to the shoulder, such as a fracture or dislocation.

Most tears, however, are the result of overuse of these muscles and tendons over a period of years. People who are especially at risk for overuse are those who engage in repetitive overhead motions. These include participants in sports such as baseball, tennis, weight lifting, and rowing.

Rotator cuff tears are most common in people who are over the age of 40. The blood supply to the rotator cuff diminishes with age and transiently with certain motions and activities. The substance of the tendon itself degenerates over time. Because of the decrease in tendon blood supply, the body's ability to repair tendon damage is decreased with age; this can ultimately lead to a full-thickness tear of the rotator cuff.

Rotator cuff tear may often happen as a result of wear and tear. An extrinsic factor that can cause damage to the rotator cuff is the presence of bones spurs underneath the acromion. The spurs rub on the tendon when the arm is elevated; this is often referred to asimpingement syndrome. Combining this with a diminished blood supply, the tendons have a limited ability to heal themselves. These factors are at least partly responsible for the age-related increase in rotator cuff disease and the higher frequency in the dominant arm.

Younger people tend to have rotator cuff tears following acute trauma or repetitive overhead work or sports activity.

Symptoms

Some of the signs of a rotator cuff tear include:

  • Atrophy or thinning of the muscles about the shoulder
  • Pain when lifting the arm
  • Pain when lowering the arm from a fully raised position
  • Weakness when lifting or rotating the arm
  • Crepitus or crackling sensation when moving the shoulder in certain positions

Symptoms of a rotator cuff tear may develop right away after a trauma, such as a lifting injury or a fall on the affected arm. When the tear occurs with an injury, there may be sudden acute pain, a snapping sensation and an immediate weakness of the arm. Symptoms may also develop gradually with repetitive overhead activity or following long-term wear. Pain in the front of the shoulder radiates down the side of the arm. At first, the pain may be mild and only present with overhead activities, such as reaching or lifting. It may be relieved by over-the-counter medication such as aspirin or ibuprofen.

Over time the pain may become noticeable at rest or with no activity at all. There may be pain when lying on the affected side and at night.

Diagnosis

Diagnosis of a rotator cuff tear is based on the symptoms and physical examination. X-rays, and imaging studies, such as MRI or ultrasound, are also helpful.

Physical examination includes looking for any tenderness or deformity including the Impingement sign . Range of motion of the shoulder is measured in several different directions and the strength of the arm is tested . We also check for instability or other problems with the shoulder joint.

We will also examine the neck to make sure that the pain is not coming from a " pinched nerve " in the cervical spine and to rule out other conditions, such as osteoarthritis or rheumatoid arthritis.

Plain X-rays of a shoulder with a rotator cuff tear are usually normal or show a small spur. For this reason , an MRI may be required to better visualize soft tissue structures such as the rotator cuff tendon .The MRI can tell how large the tear is, as well as its location within the tendon itself or where the tendon attaches to bone.

MRI Scan image shows a full-thickness rotator cuff tear within the tendon.
Rotator Cuff Tears and Treatment Options

Treatment recommendations vary from rehabilitation to surgical repair of the torn tendon(s). The best method of treatment is different for every patient.

The decision on how to treat rotator cuff tears is based on the patient's severity of symptoms, functional requirements, and presence of other illnesses that may complicate treatment.

Nonsurgical Options

Non Surgical treatment typically involves activity modification (avoidance of activities that cause symptoms). This treatment can provide pain relief and improve the function of the shoulder of a rotator cuff tear in approximately 50% of patients

Nonsurgical treatment options may include:

  • Rest and limited overhead activity
  • Use of a sling
  • Anti-inflammatory medication
  • Steroid injection
  • Strengthening exercise and physical therapy

We recommend nonsurgical treatment for patients who are most bothered by pain, rather than weakness, because strength does not tend to improve without surgery.

Disadvantages of nonsurgical treatment are

  • Strength does not improve
  • Tears may increase in size over time
  • Patient may need to decrease activity level
Surgical Intervention and Considerations

Surgery is recommended if

  • Nonsurgical treatment does not relieve symptoms
  • The tear has just occurred and is very painful
  • The tear is in the shoulder of the dominant arm of an active person
  • If maximum strength in the arm is needed for overhead work or sports

The type of surgery performed depends on the size, shape, and location of the tear. A partial tear may require only a trimming or smoothing procedure, called a debridement. A complete tear within the thickest part of the tendon is repaired by suturing the two sides of the tendon back together. If the tendon is torn away from where it inserts into the bone of the arm (humerus), it is repaired directly to bone.

During surgery to repair a torn rotator cuff , if there are bony spurs , they are removed along with a part of the acromion bone called Acromioplasty . Other conditions such arthritis of the AC joint or tearing of the biceps tendon may also be addressed.

The three commonly used surgical techniques for rotator cuff repair are:

  • Open repair
  • Mini-open repair
  • All-arthroscopic repair

Each of the methods available has its own advantages and disadvantages; all have the same goal getting the tendon to heal to the bone. The choice of surgical technique depends on several factors, including the surgeon's experience and familiarity with a particular procedure, the size of the tear, the patient's anatomy, the quality of the tendon tissue and bone, and the patient's needs. Regardless of the repair method used, studies show similar levels of pain relief, strength improvement, and patient satisfaction.

We use special fasteners to anchor the rotator cuff to the humerus. During the procedure, we make small drill holes into the humerus. A suture anchor is punched down inside the drill hole. By tugging on the suture, the fastener becomes anchored to the bone. The tendon is then sewn together and stitched to the humerus by looping sutures over the edge of the rotator cuff.

Many surgical repairs can be done on an outpatient basis

Surgical Procedure
Open Repair

Open repair is performed without arthroscopy. We make an incision over the shoulder and detach the deltoid muscle to gain access to and improve visualization of the torn rotator cuff . We will usually perform an acromioplasty (removal of bone spurs from the undersurface of the acromion) as well. The incision is typically several centimeters long. Open repair was the first technique used to repair a torn rotator cuff; over the years, the introduction of new technology and improved surgeon experience has led to the development of less invasive surgical procedures. Although a less invasive procedure may be attractive to many patients, open repair does restore function, reduce pain, and is durable in terms of long-term relief of symptoms.

In this photograph, the typical incision size for a mini-open rotator cuff repair is shown in black on a patient''s left shoulder.

As the name implies, mini-open repair is a smaller version of the open technique. The incision is typically 3 cm to 5 cm in length. This technique also incorporates arthroscopy to visualize the tear and assess and treat damage to other structures within the joint . Arthroscopic removal of spurs (acromioplasty) avoids the need to detach the deltoid muscle. Once the arthroscopic portion of the procedure is completed, we proceed to the mini-open incision to repair the rotator cuff. Mini-open repair can be performed on an outpatient basis. Currently, this is one of the most commonly used methods of treating a torn rotator cuff; results have been equal to those for open repair. The mini-open repair has also proven to be durable over the long-term.

All-Arthroscopic Repair

Arthroscopic photographs of a rotator cuff tear (left) and the final repair (right). This was performed all-arthroscopically. Sutures were used to reattach the tendon back to bone.

This technique uses multiple small incisions (portals) and arthroscopic technology to visualize and repair the rotator cuff. All-arthroscopic repair is usually an outpatient procedure. The technique is very challenging, and the learning curve is steep. It appears that the results are comparable to those for mini-open repair and open repair.

Results

After rotator cuff repair, 80% to 95% of patients achieve a satisfactory result, defined as adequate pain relief, restoration or improvement of function, improvement in range of motion, and patient satisfaction with the procedure.

Surgical techniques for rotator cuff repair have progressed to more minimally invasive procedures. Each step toward less invasive surgery has benefited the patient by:

  • Decreasing pain from surgery
  • Decreasing postoperative stiffness
  • Decreasing surgical blood loss
  • Decreasing length of stay in the hospital

Each technique has similar results in terms of satisfactory relief of pain, improvement in function, and patient satisfaction. Less invasive surgery results in an easier rehabilitation process and less postoperative pain.

Improvement in pain, function, and strength typically occurs over a 4 to 6 month period following the procedure.

Complications

Like all surgeries , rotator cuff repair surgery has some complications seen in 2-3% of patients . These include nerve injury , infection , deltoid detachment , stiffness & tendon re-tear which can be minimised by meticulous surgical techniques .

Rehabilitation

Following rotator cuff surgery, therapy progresses in stages . Initially, the repair needs to be protected until adequate healing of the tendon to bone occurs. For this reason, most patients use a sling for the first 4 to 6 weeks after surgery and are instructed to limit active use of the arm during this period. Passive range-of-motion exercises are begun with a therapist pendulum exercises may be taught as well. Progressive strengthening and range-of-motion exercises continue during the next 6 to 12 weeks. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery.

A strong commitment to rehabilitation is important to achieve a good surgical outcome. We will examine the outcome to advise when it is safe to return to overhead work and sports activity.

Summary

The incidence of full-thickness rotator cuff tears increases with age; however, tears are not always painful. Tears can be managed successfully with nonsurgical treatment in 50% of patients. Pain and range of motion will improve with nonsurgical management, but strength will not. Large tears, significant weakness, and an acute traumatic event are possible causes of poor outcome from nonsurgical management.

Surgical repair results in pain reduction and improved function and strength in more than 80% of patients. About 2-3% of surgeries can result in complications. Surgical procedures to repair a torn rotator cuff have become increasingly less invasive. Minimally invasive procedures are less painful and have less blood loss, shorter hospital stays, and a generally easier rehabilitation period. Although less invasive procedures are more attractive, they are often more difficult for the surgeon to perform and require an experienced surgeon for best results. Lastly, all repair methods appear equal in outcomes when the surgery is performed well.