 |
|
|
|
Rotator Cuff:
The term "rotator cuff" refers to a group of four tendons that attach four shoulder muscles to the upper arm. When you activate those muscles, your arm moves away from your body in a variety of directions.
The shoulder is a very unique joint. It has a wider "range of motion," which means it can move more freely, and in more directions, than any other joint. The shoulder's versatility enables us to position our hand in space and hold it there while performing tasks.
The shoulder's flexibility is due to its unique structure. Like the hip, the shoulder is a "ball-and-socket" joint - a "ball" at the top of the upper arm bone (the humerus) fits neatly into a "socket" formed by the shoulder blade (scapula). This "socket" however is more of a flat disc than a true socket. It is surrounded by a rubber like rim called the "labrum" which effectively deepens the "socket" and adds stability to a potentially very unstable joint. Because of this unique anatomy the shoulder is extremely mobile and also prone to instability or dislocation.
What Is A Rotator Cuff Tear?
Injury to the rotator cuff severely effects the function of the shoulder. It is almost always associated with pain and loss of strength. If a rotator cuff tendon becomes inflamed or is partially torn, it can cause pain and limit shoulder movement.
Cuff tears can occur from an injury such as falling on your arm, from a sudden impact as might occur skiing, snowboarding, playing football or a similar collision sport, auto accidents and any number of other activities which might overload a tendon.
Cuff tears can also occur gradually as a result of years of "over-use" and from a condition within the shoulder referred to as "impingement".
Impingement occurs when the rotator cuff rubs against the acromion (the bone adjacent to the cuff). As we get older, some of us grow bone spurs on the acromion which can rub (impinge) upon the cuff tendons leading to pain, swelling and ultimately cuff failure (rotator cuff tear).
Shoulder Impingement
The most common cause of rotator cuff problems is a disorder known as impingement.
Ordinarily, the rotator cuff moves freely in the space between the top of the upper arm and a part of the shoulder blade known as the acromion, which overhangs the rotator cuff. But in some people, this space is inadequate to allow the normal smooth gliding movements of the rotator cuff as it moves the arm. Every time they raise an arm, the rotator cuff is pinched against the acromion.
In some cases, impingement is caused by accident or injury. Most often, it occurs with aging. As people grow older, their shoulder muscles and tendons weaken, causing the shoulder joint to become less stable. The space between the upper arm and the acromion narrows. The rotator cuff has less room to move. The increased pressure gradually damages the rotator cuff.
Although the rotator cuff can tear suddenly as a result of a serious injury, most rotator cuff problems develop over time. Over a period of months or years, impingement causes the rotator cuff to become irritated, to tear partially, or to tear completely.
Rotator Cuff Tendonitis (Tendonopathy)
The term tendonitis/tendonopathy refers to chronic irritation, inflammation, or degeneration of the rotator cuff that occurs as a result of impingement or overuse. Symptoms of tendonitis may come and go for months or even years. Symptoms tend to be aggravated by activity, relieved by rest but particularly bad at night.
Some shoulders also develop calcium deposits or abnormal bone growths on the acromion called bone spurs. Both can contribute to impingement causing pain, limitation of range of motion, weakness and tendon failure.
Shoulder Bursitis
A bursa (plural bursae) is a soft, fluid-filled sac that helps to cushion and lubricate surfaces that slide upon each other. In the shoulder, there are bursae located between the rotator cuff and the acromion. When a bursa becomes irritated or inflamed, it causes bursitis. This condition is painful and associated with limited range of motion and especially pain at night.
Symptoms of Rotator Cuff problems:
A sick rotator cuff can cause pain, limitation of range of motion, clicking and popping sensations within the shoulder, weakness, sensations of instability and especially pain at night.
Treatment of Rotator Cuff Conditions:
Treatment, to a large degree is dictated by the nature and extent of the damage. The first thing to do is try to make an accurate diagnosis by reviewing the history of onset of symptoms, a careful physical examination of the shoulder and x-ray examination of the shoulder. MRI of the shoulder may be useful but is often lacking in accuracy.
Questions I try to answer are:
Is it torn, partially torn or just inflamed and irritated?
Is there a bone spur, a calcium deposit or evidence of impingement of the cuff against the acromion?
Simple inflammation or bursitis can respond to rest, anti-inflammatory medication, injections and rehabilitative exercises.
Partial tears can respond favorably to similar treatment as is used for simple inflammation.
Full thickness or complete tears of the rotator cuff almost always require surgery for recovery. Bone spurs usually require surgical removal if they are contributing to impingement. Calcium deposits may respond to injections and sometimes require surgical removal.
Surgical Treatment: WHEN?
Bursitis: Not usually treated with surgery
Tendonitis: Not usually treated with surgery
Calcium deposits: Occasionally require surgical removal
Impingement: Usually requires surgical repair
Rotator Cuff Tear: Usually require surgical repair
Arthroscopic Shoulder Surgery:
Most surgery done today to treat these conditions is effectively performed employing "arthroscopic" methods. This means the surgery is performed by inserting a "scope" into the shoulder through a small puncture wound, visualizing the procedure with a special camera that puts the image on a "television" monitor and performing the repair work with small instruments inserted through one or more small additional puncture wounds. These techniques are commonly employed in the shoulder and the knee.
The surgery is almost always done in an out-patient setting. You come to the hospital or same-day surgery facility, are taken to the operating room, given an anesthetic (general or regional anesthesia or a combination of both) and then positioned on the operating table. Small puncture wounds are employed to insert the scope, fill the joint with fluid an examine all the important structures. Once the diagnosis is confirmed by direct visualization, the repair procedure is performed.
Impingement is relieved by grinding off some of the acromion (acromioplasty) sufficient to create enough room for the rotator cuff such that it no longer rubs against the bone.
Calcium deposits are easily evacuated.
Rotator cuff tears require that the tendon be sewn back to the bone. One must freshen up the surface of the bone, place anchors in the bone with sutures attached, weave the sutures through the torn end of the tendon and then tie knots to hold the tendon tightly to the bone. Recent advances allow us to use a "double row" repair to increase the strength of the repair.
The operation can last from as little as 20 minutes to correct impingement to greater than a hour to repair a large rotator cuff tear. Once the surgery is completed, the instruments are removed and "steri-strips" are applied to the small puncture wounds.
Various types of slings are applied at the end of the surgery to support or protect the surgery. A simple arm sling is used for the more minor procedures while a sling with a bolster to lift the arm slightly away from your body is used in cuff repairs and stabilization surgery.
Pain Pump:
The final thing I do at the end of the surgery is to place a small catheter under the acromion adjacent to the site of the surgery. This is inserted through a special needle and is a soft flexible tube that comes out through your skin and is taped in place. The other end of the catheter is attached to a small box or "pain pump" which is filled with a numbing medication. The medication is automatically "pumped" into our shoulder at a pre-defined rate. There is nothing for you to adjust or fiddle with. There are some brands of pumps that allow you to adjust the settings but I have found them to be confusing and potentially dangers. I use a brand that is simple and has been shown to be reliable. After approximately 48 hours the pump is empty and the catheter needs to be removed. Instructions are sent home with you (including a DVD) to teach you how to removed the pump catheter but it is quite simple. You removed the bandage, see the catheter coiled up on the surface of your skin under a "cellophane" like piece of tape. Remove the tape and pull out the catheter. It almost falls out. It comes out quite easily. DO NOT CUT IT OFF AND LEAVE IT IN YOUR SHOULDER! Once the catheter is out you can put a small band-aide over the site.
Why a Pain Pump?
Pain pumps dramatically reduce post operative pain. The first two days following rotator cuff surgery is the worst. The pain pump makes that part of the recovery much easier.
|
|
|
|
|
|
|
|
|
