William T. Pennington, M.D.
The Orthopedic Institute of Wisconsin
What is the Rotator Cuff?
The rotator cuff is comprised of the tendons of four muscles that originate on
the scapula (shoulder blade) that attach to the proximal humerus. The
functioning rotator cuff will keep the humeral head (ball) centered in relation
to the glenoid surface (cup) during shoulder motion while also serving to
provide muscular force in planes of shoulder motion including forward flexion,
abduction, internal and external rotation.
The muscles that make up the rotator cuff are as follows:
||Initiates shoulder flexion and abduction, most commonly torn tendon.
||External Rotator of the shoulder.
|Teres Minor muscle:
||External rotator of the shoulder.
||Internal rotator of the shoulder.
What happens when the rotator cuff is injured?
Rotator cuff injuries that are typically encountered are those that involve
inflammation of the tendon (tendinopathy) and overlying bursa (bursitis) or
tearing of the rotator cuff attachment to the proximal humerus. Patients often
present with a painful shoulder that is worsened with any type of reaching or
lifting of the arm. Typically patients will complain of pain on the top of the
shoulder with radiation of pain down the front and side of the arm in the biceps
and deltoid region. When the tendinous attachment of the rotator cuff is torn
away from the proximal humerus this pain can be accompanied by significant
weakness during arm motion or even the inability to move the arm actively is
Inflammation of the rotator cuff can occur from episodes of increased activities
resulting in an acutely painful state or inflammation can result from prolonged
insults to the shoulder that occur during everyday activities. An extrinsic
factor that can predispose patients to rotator cuff injuries and inflammation is
the presence of a “bone spur” on the undersurface of the acromion, the bone
directly over the rotator cuff, which can cause mechanical impingement to the
underlying rotator cuff during certain motions of the shoulder. This impingement
can cause repeated injuries to the underlying rotator cuff tendons resulting in
inflammation, tendinopathy, bursitis and sometimes tears of the rotatorcuff.
of the rotator cuff typically occur in varying degrees of magnitude. They can be
partial thickness in nature in which a portion of the thickness of the tendinous
attachment is torn away from the bony attachment or full thickness in which the
entire thickness of the rotator cuff tendon is torn away from the proximal
humerus. Tears can involve only a portion of a single tendon or they can be so
large that they can involve the entire tendinous attachment of one or more of
the rotator cuff tendons (Figure 1).
The attachment site of the rotator cuff
tendon to bone is an area that does not have any blood supply, therefore,
rotator cuff tears don’t typically heal spontaneously back to the bone.
How do we treat rotator cuff problems?
It is difficult to have a set treatment protocol for all rotator cuff injuries
as each case needs to be considered on an individual basis to determine the most
appropriate course of action that should be employed. When presented with a
patient complaining of shoulder pain that appears to be attributable to the
rotator cuff region we need to collect data that will help us diagnose the
problem and hopefully prescribe a regimen that will eventually result in the
patient regaining lost function and experience pain relief.
begin with a patient history and physical examination focusing on when the
problem occurred, how it occurred, what makes it better or worse and what has
been attempted up to the point of our evaluation to try to make things better.
We examine the patient focusing on appearance, range of motion both active and
passive, strength of the shoulder in all of the motion planes, palpation of the
rotator cuff attachment, and finally we perform certain physical examination
tests that help predictably diagnose the problem. We will often obtain standard
radiographs (x-rays) of the shoulders to evaluate for the presence of the spurs
on the undersurface of the acromion and to also evaluate for any other bony
problems such as arthritis that may be contributing to the painful condition. It
is very important to also evaluate the cervical spine (neck) region to also rule
out any problem in that area that may be causing the current pain in the
shoulder. Occasionally, if an acute traumatic event such as a fall precipitated
the pain and we’re concerned that this traumatic event caused a rotator cuff
tear in a young active patient we’ll proceed to ordering advanced imaging
techniques such as a MRI scan to thoroughly evaluate the rotator cuff prior to
instituting a treatment plan.
Treatment of rotator cuff injuries often begins with a period of rest from
activities that may exacerbate the pain. We often utilize anti-inflammatory
pills if possible to help with the pain and inflammation and prescribe physical
therapy. The physical therapist will focus on re-gaining or maintaining motion
of the shoulder joint that may diminish due to the painful state of the affected
shoulder. They often also employ modalities such as ultrasound or iontophoresis
to help with the inflamed state providing pain relief. When the patient has a
shoulder that has a full range of motion and has reasonable pain relief the
therapist will then focus on strengthening the rotator cuff muscles as well as
other muscles surrounding the region that may eventually lead to the restoration
of function and proper kinematics of the shoulder joint hopefully leading to a
complete functional recovery that is satisfactory to the patient. When a patient
benefits from this type of treatment, typically this benefit begins to occur
after four to six weeks of physical therapy. Sometimes the shoulder is too
painful to tolerate the therapy and in these instances we may also suggest a
cortisone injection to help with the pain so the patient is able to tolerate the
pain while hopefully recovering without needing more aggressive treatment.
Cortisone injection is a commonly used, often feared, treatment that can be
quite beneficial to assist patients in recovering from a rotator cuff injury or
inflamed state. Cortisone is an injectable anti-inflammatory agent that we are
able to administer directly to the site of injury hopefully resulting in
significant pain relief and reduction in inflammation. We typically employ one
injection in conjunction with other treatment modalities such as therapy to
hopefully help the patient recover the function that they’re after. If another
injection is necessary we will offer it twelve weeks after the initial injection
only if the initial injection was beneficial and has worn off. We do not think
that any more injections than two are beneficial due to possible weakening of
the rotator cuff with repeated injections (greater than three) and the
significantly higher failure rate of surgeries that occurs in patients that
eventually undergo rotator cuff repair surgery that have had more than three
cortisone injections in the operative shoulder.
If all of the non-surgical treatment modalities fail, we do sometimes need to
employ surgical methods to help facilitate recovery and restoration of shoulder
function in patients afflicted with rotator cuff problems. Of note, there are
some instances such as the young active patient with an acute traumatic full
thickness rotator cuff tear that we typically recommend proceeding with surgical
repair immediately. These patients tend to demonstrate better clinical outcomes
with acute repair of these injuries rather than in the setting of delayed
When considering rotator cuff repair an imaging study such as a MRI scan is
useful to determine reparability of the rotator cuff by evaluating the
retraction, tissue quality and associated atrophy of the muscle. This data is
useful when preoperatively counseling the patient about perceived benefits of
proceeding with an operative approach. As one would intuitively infer, those
with larger retracted tears with associated muscle atrophy are less predictably
repaired than those with smaller non-retracted tears with minimal to no muscle
How do we surgically approach rotator cuff problems?
Surgical intervention in the instance of rotator cuff injuries is typically
taken care of arthroscopically. Arthroscopy is a surgical approach utilizing a
small camera, an arthroscope, to completely examine the shoulder structures
including the rotator cuff to determine exactly what needs to be done. If there
is a spur on the undersurface of the acromion causing impingement of the rotator
cuff it is removed using a burr to alleviate the impingement and pain that the
spur may be responsible for causing. The rotator cuff is thoroughly evaluated
and if there is a tear the rotator cuff is repaired as well. Techniques have
evolved that now allow us to repair most rotator cuff tears through an
arthroscopic approach. By utilizing this technique of rotator cuff repair the
advantage for patients is that there is less invasion of the overlying soft
tissue, therefore, less trauma occurs and theoretically there is less of a
chance that stiffness or loss of motion will occur post- operatively.
The technique of arthroscopic rotator cuff repair is depicted in Figure 2 and
video footage of a simulated repair can be seen at
Initially the arthroscope is inserted into the shoulder joint through a small
incision in the back of the shoulder to assess the entire shoulder joint. There
are instances that other injuries do exist that wouldn’t necessarily be seen if
an open surgery was performed. If problems are seen with the arthroscope they
can typically be addressed during the arthroscopy as well by placing instruments
into the shoulder joint through a cannula placed through an anterior portal.
After all of the pathology is addressed the rotator cuff tear is evaluated and
the repair technique that will be employed is determined based on the anatomy of
the tear. If there is a spur present a subacromial decompression is performed to
alleviate any impingement present.
The rotator cuff tendon is generally repaired by reattaching the torn tendon
back to the proximal humerus to the site that it was torn away from. The site of
reattachment is referred to as the “footprint” of the rotator cuff. The
footprint is the area on the humerus that the rotator cuff normally attaches to.
When performing these repairs arthroscopically a device called a rotator cuff
anchor is typically used to perform this reattachment. The anchor that we
utilize is a screw made out of bioabsorbable plastic the we can insert into the
proximal humerus just to the outside of the rotator cuff footprint. Prior to the
insertion of this anchor a burr is used to remove the bone on the humerus that
is overlying the footprint to create a trough in the footprint that has a
bleeding surface. The anchor is then placed just outside this trough and sutures
that are attached to the anchor are passed through the rotator cuff where it is
torn away from the bone. After this process is complete the sutures are tied and
this results in the reattachment of the rotator cuff tendon to the proximal
humerus over the bleeding footprint.
repair technique is strong, however, it is not strong enough to withstand active
use of the shoulder muscles that have been reattached. This process typically
takes six weeks for the initial phases of healing to occur and at least another
six weeks for the healing tissue to mature. The actual healing that takes place
is that the bone on the footprint that is burred bleeds under the repaired
rotator cuff resulting in a hematoma being formed that eventually leads to the
healing of the rotator cuff to the footprint over time. Due to this healing and
maturation process the repair needs to be protected so that the repair is not
ruined prior to the time that healing occurs. Therefore, active forward
elevation and sideways elevation actively is not allowed for 6 weeks post-
operatively. We do allow passive motion of the shoulder and in fact utilize a
machine that will provide this passive motion to help decrease the occurrence of
stiffness that may occur in these patients post- operatively.
What is the post-operative protocol?
Patients are typically kept in a sling after surgery to serve as a reminder
about the fact that they are not allowed to actively move the arm. Immediately
post-operatively a polar ice pack is placed on the shoulder to help decrease the
inflammation and pain. The continuous passive motion (CPM) machine that is
supplied is generally started the day after surgery and advanced as the patients
tolerate. The patient returns to the office five to seven days post-operatively
for suture removal from their four small incisions and then return at the five
week point for a passive motion check. Physical therapy typically begins three
weeks after surgery and focuses on pain relief and passive motion initially
followed by the advancement to active motion and strengthening of the repaired
cuff when appropriate.
We have studied long term outcomes of arthroscopic rotator cuff repairs in
patients and, if everything goes well, full recovery occurs in three to four
months on average. Occasionally conditions such as excessive postoperative
stiffness may prolong this recovery period.
In rare occasions the tear is so large that it is not reparable. In these
instances sometimes debridement of the shoulder joint and rotator cuff tear with
removal of spurs that may be present results in decreased pain in the shoulder.
If severe arthritis is present with one of these massive irreparable tears a
shoulder replacement procedure is sometimes required to provide pain relief that
Our goal at The Orthopedic Institute of Wisconsin is to provide high quality
care both non-surgical and surgical that eventually will allow patients to
regain lost function and experience pain relief that will hopefully result in
the improvement of their quality of life. Through state of the art care our aim
is to facilitate our patients return to a pre-injury level of function that
ultimately will be satisfactory to our patients.
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