Though a shoulder replacement is a last resort for pain and mobility issues, more than 50,000 people need one each year. Read on to find out if you’re one of them.
In this video, Shoulder Specialist Dr. J. Michael Bennett describes the anatomy of the shoulder rotator cuff and rotator cuff treatment. Dr. Bennett is a Board Certified Orthopedic Surgeon and a Fellowship-Trained Sports Medicine Specialist with many years of experience in treating shoulder injuries.
Dr. Bennett serves patients from his clinics in Sugar Land, near First Colony Mall, and in Houston, near the Galleria. Call 281-633-8600 for appointments at our Sugar Land clinic and 713-234-3152 at our Houston clinic.
Hello, my name is J. Michael Bennett. I am an orthopedic surgeon, my specialty is in sports medicine. I’m fellowship trained in sports medicine; shoulder, elbow, and knee arthroscopy; and minimally invasive surgery.
Today, I just wanted to go over some basics in regards to shoulder pathology and shoulder problems. The first thing that I want to talk about is shoulder rotator cuff issues. This is the first of a series of talks that we’ll be doing online. We’re gonna call these the Whiteboard Series.
So if you have any interest in any of the orthopedic issues, we will have these online as well, so welcome. First off, let’s go over the basics of the shoulder. Here is a typical shoulder. This is the bony anatomy of the shoulder. So you have a ball and you have a socket. And they basically fit like this.
Now surrounding this bony anatomy, you have a number of muscles and these muscles are the rotator cuff — they comprise the rotator cuff. The rotator cuff gives you the rotation and technically, looks like a cuff of tissue that surrounds this ball and socket mechanism. The rotator cuff, this is just a larger version here.
The rotator cuff involves subscapularis, which is the tendon muscle, the muscle tendon complex in the front of the shoulder. The supraspinatus, which is on top of the shoulder. Then you have the infraspinatus on the back and then the teres minor below here.
So those four muscles allow you to have forward flexion, which is in front of your body, and abduction, abduction external rotation and internal rotation. They give you
strength and when you do have an injury to the rotator cuff, particularly a rotator cuff tear is when you notice significant weakness and debilitation with the shoulder.
You may have pain when you’re sleeping at night, pain with any kind of overhead activity. Some patients will describe a lifting a heavy object and feeling a pop or click in their shoulder.
Sometimes actually it could be a rotator cuff tear or it also could be a tear in the biceps tendon, which is this long tendonous structure here that runs up right in the front area of the shoulder and it connects to the biceps. It’s called the long head of the biceps. If you have a rupture of the long head of the biceps, most patients will present with a lot of bruising and sometimes a larger biceps because once this tendon retracts, you get fullness on that side. We actually call that a Popeye deformity.
So anyway today, I wanted to just go over some of the basics in regards to rotator cuff pathology. What rotator cuff tear typically looks like and really just break it down into the nuts and bolts of what a rotator cuff tear is, how we fix it. So basically here is your ball and socket, okay. Apologize for my artwork here but we’ll try to make it work.
As we mentioned before, supraspinatus is the muscle tendon unit at the top of the shoulder. The supraspinatus comes down and inserts on this tuberosity right here. That actually gives you strength with abduction, when you lift your arm up above your head. The deltoid also helps with that, but the supraspinatus, it also assists with the deltoid and gives you full strength with overhead activities.
When you have a tear, there are different types of injuries of the rotator cuff that you can have. You can have tendinosis of the rotator cuff, which means it usually occurs from overuse activities. It’s really kind of a dull aching constant shoulder pain that doesn’t seem to go away.
Typically, it’s seen on MRI and a lot of times what we’ll see on MRI is a lot of fluid uptake and swelling within the tendon. And so this portion of the tendon, this is the muscular portion. And this here is the tendinous portion. So what happens in the tendinous portion particularly at its insertion site here, you’ll get a lot of fluid and a lot of swelling in this area. And that will increase the signal on MRI and it looks like tendinosis and we call it tendinosis.
Now a mild form of that is tendinitis, which is just the inflammation. Tendinosis is actually when you have the changing of the tendon itself, when it becomes actually looks a little more degenerative and actually looks more swollen. This can be very painful, a lot of times this can respond to just an injection, a subacromial injection, which would be just an injection right in this space. In this area to see if a little lidocaine and steroid will actually calm down some of this inflammation in addition to a good therapy program to help balance out the shoulder structures and give you back your range of motion. Most patients actually will respond to that. So that’s tendinosis and tendinitis basically.
You can also have some partial tears in the tendon. And depending on the type of partial tear you have, will determine what type of treatment options available to you. In addition to that, it also depends on your symptoms.
A partial tear is when basically the rotator cuff has a large footprint. When I say footprint it’s where the tendon inserts onto the bone. So the footprint here is this whole region right here. This is the footprint of the rotator cuff. All inserts down into the tuberosity. So if you have partial tear of that footprint, part of that footprint is now gone, okay. And it creates a defect like that.
So what used to be a full intact tendon is now partially attached. We have a partial tear a lot of times, partial tears are treated without surgery. You can actually treat partial tears with a good therapy program and sometimes an injection will help as well with a partial tear.
There are a lot of people out there that have partial tears of the rotator cuff that are asymptomatic. They don’t have symptoms. If we scanned everybody’s shoulder that came into the office, we’ll probably find a lot of partial tear rotator cuffs in patients that don’t have any problems.
The problem is when you actually have symptoms and when the symptoms don’t go away or don’t respond to any conservative measures. Like I said before, we start out with therapy, injection, rest, modification of activities. If you continue to have pain, then we get an MRI to look at the tendon and see exactly how badly torn it is and how much of that tendon is detached.
If we look at the tendon and it’s significantly detached, there’s sometimes we see tendons that are detached down to a few fibers here. A majority of that tendons detached and there’s maybe a strand or two that’s still intact there, so technically they’re still able to raise their arm above their head, but they’re having this pain that’s not responding to conservative measures. And that’s when we actually start think about pursuing something like surgery.
If we do go along the lines of surgery, we usually use an arthroscope, which is a small camera that we put into the shoulder joint through some poke holes in the shoulder. Then evaluate exactly how much is torn.
Now when I say that, you make ask, “Well Doc, you got an MRI “that says it’s torn so it must be torn.” Well I’ll tell you this, there are different MRIs out there and the quality of the MRI depends on the magnet. And so you may very well get an MRI that says you got a tear in the rotator cuff, but let’s say you can move your arm and you have no pain and you feel great.
That MRI may not be a good quality MRI and even though it says it’s a tear, it may not be a tear and vice versa. There may be a tear even though it doesn’t say there’s a tear. So a lot of times you really gotta base it on the patient and how they respond to the treatment. And then use the MRI to kind of back up your initial diagnosis.
Don’t get me wrong, MRIs are very helpful, but I just don’t base everything on MRI findings. So I always tell patients before we do a scope or a surgery, we may find more than what the MRI shows. And if that’s the case, at least the patient is prepared for other potential outcomes of the surgery.
So that being said for determining the rotator cuff treatment, what we do is we look at the rotator cuff tendon and see how much is torn. If it’s less than 50% torn, being half of that tendon still intact, and only 50% is elevated, a lot of times we can just go in there and debride some of the degenerative tissue and leave the tendon alone and that’s it. The recovery on that is very quick.
Now if it’s greater than 50% torn, then such as this, then we have to go in there and basically create a nice bleeding surface here in the bone, like a footprint. And then we put some anchors in there. When I say anchors, basically the anchors go through the bone here and they have basically, they can be little screws or little absorbable anchors that are either made of synthetic bone type products or metal, either way there are two stitches that come out of these anchors, two sutures. And these sutures are passed through the rotator cuff tendon and come out on top of the tendon and they pass through another portion of the tendon and then come on top of the tendon. Through the camera, we tie these together and we pull it down.
That pulls this whole tendon back down to bone and it lies flat on the bone. It holds that tendon back to where it’s supposed to be in its normal position. The fact that we went ahead and created a little bit of bleeding in this bone here gives it a nice footprint for ingrowth.
When we say ingrowth that means we want to have happen is the tendon and the bone grow in together and actually create a nice stable construct. Or you can say scar tissue, whichever you prefer. But either way, the tendon is reattached down to the bone. Now when we do a rotator cuff repair, that’s a big difference than just doing a debridement as far as recovery and rehabilitation. You may want to talk to your doctor about it, see what their protocol is.
For my protocol, it’s usually four weeks in a sling. We start you at passive motion after being in a sling for a period of weeks. We don’t start strengthening until about three months or so. Most patients are returning to full activity at about four to six months. It varies just depending on the type of tear. This is a very straightforward, standard tear.
Now sometimes we could have different types of tears. This here is, let’s say we’re looking at the shoulder now from another view. We’re looking at the shoulder now from the top down view. Okay so this is just basically, if I were taking a camera and pointing it above my head looking down at my shoulder. This is what you would see looking top down. So if you have a shoulder like this, and you want to tilt it this way, this is what you would be seeing, okay. So the different types of tears you can have.
Obviously, you can have one tear of the supraspinatus tendon, but you can also have tears of the muscles in the front and back of the shoulder too that allow for external-internal rotation to give you the strength there. And sometimes if you get a tear that’s large enough, the shoulder actually can dislocate because it no longer has it’s stable structures there supporting it. We see this sometimes in traumatic tears, particularly in older patients that when they do dislocate their shoulder, they oftentimes tear their rotator cuff.
Sometimes we’ll see this is at the biceps tendon here, the little round thing that actually runs up here to the front of the shoulder here. It comes right there. This is on two views looking at it. If you do have a tear of this front tendon here, the subscapularis, and this tendon retracts, sometimes this biceps can also pop over and become unstable. And actually that biceps, it’s supposed to be in the groove right here is now over here and that becomes a problem. It can be very painful, it could be a lot of popping and clicking in the shoulder joint.
This is considered an unstable biceps. And that needs to be addressed as well with surgery. And there’s a number of ways to address an unstable biceps or a degenerative or a torn biceps because sometimes these biceps tendons can be torn or degenerative. And we’ll talk about that in another talk when we talk about instability of the shoulder and dealing with superior labral tears and things like that.
But right now when it comes to rotator cuffs, basically, my point is that you have a number of muscular tendinous structures that surround this ball and socket mechanism. You can have one tear of one tendon, you can have tear of all four tendons. And depending on the type of tear determines what type of option you have regarding surgery or non-operative management for your rotator cuff treatment.
Now let’s just say what happens when you tear your tendon and you don’t do anything about it. And this is a big problem, it can become a big problem. So if you have your bone socket here, and you have your rotator cuff again here, okay it’s attached there, and then you get a tear. And so you get a tear that’s disrupted here. Well the first thing that happens over a period of time is that tendon wants to spring back. It wants to go back this way. That’s called tendon retraction.
The rotator cuff is a muscle so muscle fibers stretch, and they’re pliable. If you get a tear or detachment of where that tendon used to insert in the bone, it will retract and the longer it’s detached, the more it’s going to retract and the harder it’s gonna be to fix. Because what happens over time is that tendon, they start off torn here, and not displaced at all and then keeps on retracting, sometimes to the point where it’s all the way here.
If you have nothing here. There’s nothing there, but your acromion and your clavicle up top that are just there to block it. So what happens if you have no muscle or tendon there to help create a stable construct for your ball and socket mechanism, you get what’s called a humeral migration where the humeral head here migrates up.
When the humeral head migrates up, then this construct is off kilter. So this now is not in alignment with the socket anymore. The humeral head migrates up, this is still down here. But is no longer in line with the humeral head, so you develop arthritis. Severe arthritis. And it’s actually called rotator cuff arthropathy. And this is what you want to prevent. Because what it can one time be addressed with a minimally invasive surgery like a rotator cuff repair arthroscopically through some poke holes like this, the outcome in this is severe glenohumeral arthritis, which is what you want to avoid.
The one way you can avoid that is if you do have a rotator cuff tear especially a single tendon tear, you want to prevent migration of that humeral head, you want to prevent retraction of that tendon. I recommend fixing it. And you can do that through a minimally invasive procedure such as through arthroscopic rotator cuff surgery like I mentioned here with the anchors and the sutures and done all through minimally invasive procedure.
Because if you do end up with rotator cuff arthropathy or a chronically retracted rotator cuff tendon with a glenohumeral mismatch creating arthritis, the only way you can take care of this is through a shoulder replacement. That’s a total shoulder replacement. The special term for a replacement is called a reversed total shoulder arthroplasty.
So which is a much bigger surgery and a longer recovery than an arthroscopic rotator cuff repair which would be done through some simple poke holes in the shoulder. So it’s obviously better to do this early than to wait.
Another reason to fix it early is that it’s easier for the surgeon to fix it early. Your prognosis is better if you fix it earlier because once this starts to retract, muscles fibers when you’re not using them, turn to fat. They actually turn to fat and scar and if they’re not being used or not being challenged, they’re gonna retract, they’re gonna scar up and when the surgeon gets in there to try to fix the rotator cuff, they’re gonna try to pull this tendon back down to the bone. And you see all this distance that that tendon has to go, and if this is already turned to scar and to fat, and it’s just atrophic muscle, you can’t get it over there. And it’s gonna be too much tension on it and it will not heal and you will undergo a surgery that could have been avoided if you had just fixed it earlier in the first place.
So that’s what you really want to avoid, so if you do have chronic shoulder problems or if you’ve been diagnosed with a rotator cuff tear in the past, go see your surgeon. A lot of times MRI can show us if it’s a good MRI, can show us exactly how much fat and scar tissue you have within that muscle belly and tendon there. That gives us a little bit of an idea of whether or not it’s repairable or not. But you have to be evaluated.
I recommend seeing an orthopedic surgeon for rotator cuff treatment, particularly one with sports medicine experience who can tell you a little bit about that and what your options are. So in a nutshell that really covers some basics in rotator cuff repair. Hopefully that gave you a little bit of guidance. If you have any questions, please feel free to visit our website at www.orthopedicsportsdoctor.com. Or feel free to call my office at 281-633-8600. I hope this was educational for you and we’ll see you at the next Whiteboard Series. Thank you.
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