A rotator cuff tear is a common cause of pain and disability among adults with close to 2 million people in the United States reporting going to their doctors because of a rotator cuff problem. What exactly is the rotator cuff? This group of tendons and muscles are located in the shoulder and attach the upper arm to the shoulder blade.
With the many movements of the rotator cuff it can make them very susceptible to injuries.
Listen to SMG Radio to hear Dr. Mark Kavanagh explain the function of the rotator cuff and how to prevent injuries.
Selected Podcast
Do You Have a Torn Rotator Cuff?
Featured Speaker:
Mark L. Kavanagh, MD, specializes in orthopedics and sports medicine, with a focus on injuries of the shoulder, elbow, wrist, hip, knee, foot and ankle. He also treats fractures, sprains, strains and neck pain. His expertise includes operative and non-operative treatment, surgery of the meniscus, rotator cuff, and labrum, as well as ligament and tendon repair and reconstruction of the knee and shoulder. Dr. Kavanagh has also received training in orthopedic trauma surgery while completing his residency at University Hospital in Newark, which is a Level 1 trauma center.
Mark L. Kavanagh, MD
Mark L. Kavanagh, MD, specializes in orthopedics and sports medicine, with a focus on injuries of the shoulder, elbow, wrist, hip, knee, foot and ankle. He also treats fractures, sprains, strains and neck pain. His expertise includes operative and non-operative treatment, surgery of the meniscus, rotator cuff, and labrum, as well as ligament and tendon repair and reconstruction of the knee and shoulder. Dr. Kavanagh has also received training in orthopedic trauma surgery while completing his residency at University Hospital in Newark, which is a Level 1 trauma center.
Transcription:
Do You Have a Torn Rotator Cuff?
Melanie Cole (Host): A rotator cuff tear is such a common cause of pain and disability among adults. Close to two million people in the United States went to their doctors because of rotator cuff problems. My guest today is Dr. Mark Kavanagh. He's an orthopedics and sports medicine specialist with Summit Medical Group. Welcome to the show, Dr. Kavanagh. First, I'd like you tell people a little physiology lesson, because so many people call it the "rotator cup" and they don't know exactly what this cuff is, is it a group of muscles? Is it one muscle? Tell them what is the rotator cuff?
Dr. Mark Kavanagh (Guest): Sure. The rotator cuff is a series of four tendons that connect the rotator cuff muscles to the bone. So, these rotator cuff muscles, through the tendons, allow us to internally and externally rotate our shoulders.
Melanie: The shoulders have so many movements, unlike the hip and, even the knee. They just do so many different movements so how easy is it to tear the rotator cuff?
Dr. Kavanagh: Yes. The rotator cuff is put under a lot of pressure because of the mobility that is associated with the shoulder joint. Also, a lot of our activities involve lifting, range of motion, and overhead activities, so there is a lot of strain over time that is placed on the rotator cuff. And we've seen in studies that the rotator cuff itself, just as a normal part of aging will have some degeneration and partial tearing and sometimes even full thickness tearing as patients age and get older.
Melanie: That's true, isn't it? That sometimes, it's just an aging thing and it makes you more susceptible. What else makes you more susceptible? Do certain sports contribute to this, or certain things that they do in sports, biomechanics that contribute to it?
Dr. Kavanagh: Sure. We see that patients that are participating in overhead sports such as baseball, lacrosse, volleyball, swimming. that can put additional stress onto the rotator cuff besides what you would do in normal day-to-day activities. There is a condition called "internal impingement" and that's when the arm is abducted and externally rotated, similar to a position a pitcher would be in during a windup. That would put some increased pressure on the rotator cuff and, therefore, cause it to kind of wear out a little bit faster than a patient who isn't participating in these types of activities. Then, you also have athletes that are potentially going to fall or land awkwardly on the shoulder and these things can cause acute injuries to the cuff.
So acute tears from a fall or from a trauma and, even a shoulder dislocation, if the shoulder was placed into an abnormal position or, if the shoulder comes out of place, sometimes that can also tear the rotator cuff.
Melanie: Are there some symptoms that would let people know, because maybe they're not going to hear a "pop"? Maybe it's not going to be something so obvious but there are certain symptoms that are textbook for these types of tears.
Dr. Kavanagh: Yes. Traditionally, pain is probably the number one complaint patients present with. So, pain with attempted range of motion, pain with lifting, pain with activity. Often patients will report they have pain at night during sleep, so they say during the day they sometimes can get through their normal day-to-day routine, but at night they get awoken by a pain in the shoulder. Typically, if the rotator cuff tears, it's a bigger tear and it's more advanced, we would typically see weakness, as well, so that if the muscle that's attached to the shoulder isn't attached properly, your ability to either externally or internally rotate your shoulder is going to be decreased, so weakness is a common presentation. And also, sometimes patients in a later stage will have some atrophy around the shoulder. What that means is that the muscles around the shoulder, because they're not working properly and because they're not attached, will kind of decrease in size because there's no function of that muscle, so over time it will just decrease in size and become abnormal.
Melanie: Do they fix themselves? Are they able to heal themselves?
Dr. Kavanagh: That's the downside to a rotator cuff injury is that once the rotator cuff is torn, it typically will retract a bit from where it's supposed to attach and the longer a tendon has been torn, the more retraction you can get. So, the body does not really have the ability to get that rotator cuff tendon back down to the bony insertion where it's supposed to normally attach. So, usually, if you have a full thickness tear, we know that that is not typically something that will heal. It just depends, a lot of times, how big that tear is. So, the rotator cuff tendon is composed of four tendons, so if you have a smaller tear in just one of those tendons, sometimes the remainder of the tendons will allow you to have okay function and even the strength may not be that decreased. But as a tear may get bigger or more involved, more of the rotator cuff tendons are torn and, therefore, not working properly and that can lead to increased symptoms and worse pain and weakness.
Melanie: When is surgery kind of your last option?
Dr. Kavanagh: Sure. So, for a lot of patients we do try some initial conservative treatment because we do know that for the acute tears, those are usually in younger active patients and a lot of times, those will need to be fixed more acutely. But when patients are in their 40s, and 50s, and 60s, and beyond, the fact that the rotator cuff is kind of tearing partially due to aging and just the rotator cuff has kind of some wear and tear, we will try and manage those patients with some initial conservative treatment. So, there's different things we try, but one of the first things is some medication, so an anti-inflammatory medicine sometimes will calm down if there's some associated rotator cuff tendonitis or bursitis, that will calm some of that down and give some patients relief. Steroid injections are very common for rotator cuff problems. We can put an injection into a space right above the rotator cuff called the “subacromial bursa”. That often will help patients that have some associated tendonitis and some bursitis and some pain from the rotator cuff tear. Also, physical therapy tends to be helpful, so the physical therapist will do modality type treatments which are, heat, ultrasound, and massage, TENS, some stretching exercises to help regain range of motion, and then some strengthening. If you can strengthen the remainder of the rotator cuff and some of the muscles around the shoulder, sometimes that will allow you to have pretty good function. So, physical therapy is often helpful in patients early on in this process.
Melanie: And, what's involved if you do have to do surgery?
Dr. Kavanagh: Yeah. The rotator cuff surgery itself is not a very big operation. A lot of the time nowadays we do it arthroscopically, so we're able to make some small incisions and then put a camera inside the shoulder and above the shoulder to look at the cuff tear and then put it back down to repair it, usually through something called “suture anchors”, which go into the bone and that allows us to retie the tendon back to where it belongs. So, the surgery itself is not a huge one. It's usually about an hour-and-a-half to two hours. It's a same-day procedure, so you go home afterwards. A lot of times, patients nowadays are getting blocks, which are the basically, anesthesiologists are putting some numbing medicine in the nerves that go down into the shoulder. That really helps us post-operatively control your pain. Really, the bad part about a rotator cuff repair is just the recovery itself is quite lengthy. So, for the first six weeks after a rotator cuff repair, you're going to be in a sling where you're only able to do what we call “passive range of motion”, and that means you're going to take the other arm to move the operative arm around. You can't actively fire your rotator cuff or use your rotator cuff muscles because that would put too much stress on the repair. So, that's for the first six weeks and then from week six to twelve, that's when we start active motion, meaning you're actively using your rotator cuff in your shoulder muscles. The therapists are going to help you kind of regain the range of motion and then, usually at three months on or twelve weeks, that's when you start strengthening. So, you start to use some bands and you start to use some weights to try to get the strength back in the rotator cuff. So, we have to protect you for a long period of time to allow this rotator cuff tendon to heal back down properly into the bone, so holding you back and protecting your repair will cause you to develop some stiffness and weakness. For most patients, I tell you that it takes about 6-12 months to completely recover from a rotator cuff surgery. At six months you'll be feeling pretty good, but from six months to twelve months, you'll definitely have more improvement, you'll get stronger and you'll have better flexibility.
Melanie: And then does scar tissue develop?
Dr. Kavanagh: Occasionally, it does, yes. Stiffness and weakness are kind of a normal complication from this surgery. That's why it's pretty important to be in physical therapy and not only to go to therapy but also to work on an exercise program at home. But, yes, occasionally patients will get a lot of scar tissue and kind of have limited mobility. I wouldn't say that this is very common but sometimes patients will need to go back in for a procedure called “a manipulation under anesthesia”. That's where we kind of break up some of the scar tissue when the patient's asleep so we're able to kind of move the shoulder without causing pain. But, again, that's not something that's kind of frequently done. It's for patients that develop stiffness in the shoulder that's not really responding to therapy.
Melanie: Is there any prevention?
Dr. Kavanagh: I would say that keeping the shoulder muscles active and in good shape is probably some prevention; if you can keep the muscles strong with lower-impact activities. Less weights, higher reps are things that are only going to put too much stress on the rotator cuff. We kind of want to keep everything strong, but we don't want to overdo it and cause too much stress, but overall keeping the shoulder healthy will keep it functioning more properly and, therefore, you'd be less likely to develop problems down the road from the rotator cuff itself.
Melanie: Dr. Kavanagh, in just the last few minutes, tell us about your team at Summit Medical Group.
Dr. Kavanagh: Sure. We're very excited that we're opening up a new orthopedic office in Warren, New Jersey, and it's an office that has a multi-specialty types of musculoskeletal doctors. We have some orthopedic surgeons who specialize in sports medicine and surgery. We have some physical medicine rehab doctors. We have some podiatry doctors, so we can really meet all the needs of our patients with pretty much any type of musculoskeletal problem. This office that's being opened is primarily all going to be all orthopedics. It’s really kind of directed at meeting all the needs of patients in this area.
Melanie: Thank you so much. What great information. You're listening to SMG Radio. For more information, you can go to summitmedicalgroup.com. That's summitmedicalgroup.com. This is Melanie Cole. Thanks so much for listening.
Do You Have a Torn Rotator Cuff?
Melanie Cole (Host): A rotator cuff tear is such a common cause of pain and disability among adults. Close to two million people in the United States went to their doctors because of rotator cuff problems. My guest today is Dr. Mark Kavanagh. He's an orthopedics and sports medicine specialist with Summit Medical Group. Welcome to the show, Dr. Kavanagh. First, I'd like you tell people a little physiology lesson, because so many people call it the "rotator cup" and they don't know exactly what this cuff is, is it a group of muscles? Is it one muscle? Tell them what is the rotator cuff?
Dr. Mark Kavanagh (Guest): Sure. The rotator cuff is a series of four tendons that connect the rotator cuff muscles to the bone. So, these rotator cuff muscles, through the tendons, allow us to internally and externally rotate our shoulders.
Melanie: The shoulders have so many movements, unlike the hip and, even the knee. They just do so many different movements so how easy is it to tear the rotator cuff?
Dr. Kavanagh: Yes. The rotator cuff is put under a lot of pressure because of the mobility that is associated with the shoulder joint. Also, a lot of our activities involve lifting, range of motion, and overhead activities, so there is a lot of strain over time that is placed on the rotator cuff. And we've seen in studies that the rotator cuff itself, just as a normal part of aging will have some degeneration and partial tearing and sometimes even full thickness tearing as patients age and get older.
Melanie: That's true, isn't it? That sometimes, it's just an aging thing and it makes you more susceptible. What else makes you more susceptible? Do certain sports contribute to this, or certain things that they do in sports, biomechanics that contribute to it?
Dr. Kavanagh: Sure. We see that patients that are participating in overhead sports such as baseball, lacrosse, volleyball, swimming. that can put additional stress onto the rotator cuff besides what you would do in normal day-to-day activities. There is a condition called "internal impingement" and that's when the arm is abducted and externally rotated, similar to a position a pitcher would be in during a windup. That would put some increased pressure on the rotator cuff and, therefore, cause it to kind of wear out a little bit faster than a patient who isn't participating in these types of activities. Then, you also have athletes that are potentially going to fall or land awkwardly on the shoulder and these things can cause acute injuries to the cuff.
So acute tears from a fall or from a trauma and, even a shoulder dislocation, if the shoulder was placed into an abnormal position or, if the shoulder comes out of place, sometimes that can also tear the rotator cuff.
Melanie: Are there some symptoms that would let people know, because maybe they're not going to hear a "pop"? Maybe it's not going to be something so obvious but there are certain symptoms that are textbook for these types of tears.
Dr. Kavanagh: Yes. Traditionally, pain is probably the number one complaint patients present with. So, pain with attempted range of motion, pain with lifting, pain with activity. Often patients will report they have pain at night during sleep, so they say during the day they sometimes can get through their normal day-to-day routine, but at night they get awoken by a pain in the shoulder. Typically, if the rotator cuff tears, it's a bigger tear and it's more advanced, we would typically see weakness, as well, so that if the muscle that's attached to the shoulder isn't attached properly, your ability to either externally or internally rotate your shoulder is going to be decreased, so weakness is a common presentation. And also, sometimes patients in a later stage will have some atrophy around the shoulder. What that means is that the muscles around the shoulder, because they're not working properly and because they're not attached, will kind of decrease in size because there's no function of that muscle, so over time it will just decrease in size and become abnormal.
Melanie: Do they fix themselves? Are they able to heal themselves?
Dr. Kavanagh: That's the downside to a rotator cuff injury is that once the rotator cuff is torn, it typically will retract a bit from where it's supposed to attach and the longer a tendon has been torn, the more retraction you can get. So, the body does not really have the ability to get that rotator cuff tendon back down to the bony insertion where it's supposed to normally attach. So, usually, if you have a full thickness tear, we know that that is not typically something that will heal. It just depends, a lot of times, how big that tear is. So, the rotator cuff tendon is composed of four tendons, so if you have a smaller tear in just one of those tendons, sometimes the remainder of the tendons will allow you to have okay function and even the strength may not be that decreased. But as a tear may get bigger or more involved, more of the rotator cuff tendons are torn and, therefore, not working properly and that can lead to increased symptoms and worse pain and weakness.
Melanie: When is surgery kind of your last option?
Dr. Kavanagh: Sure. So, for a lot of patients we do try some initial conservative treatment because we do know that for the acute tears, those are usually in younger active patients and a lot of times, those will need to be fixed more acutely. But when patients are in their 40s, and 50s, and 60s, and beyond, the fact that the rotator cuff is kind of tearing partially due to aging and just the rotator cuff has kind of some wear and tear, we will try and manage those patients with some initial conservative treatment. So, there's different things we try, but one of the first things is some medication, so an anti-inflammatory medicine sometimes will calm down if there's some associated rotator cuff tendonitis or bursitis, that will calm some of that down and give some patients relief. Steroid injections are very common for rotator cuff problems. We can put an injection into a space right above the rotator cuff called the “subacromial bursa”. That often will help patients that have some associated tendonitis and some bursitis and some pain from the rotator cuff tear. Also, physical therapy tends to be helpful, so the physical therapist will do modality type treatments which are, heat, ultrasound, and massage, TENS, some stretching exercises to help regain range of motion, and then some strengthening. If you can strengthen the remainder of the rotator cuff and some of the muscles around the shoulder, sometimes that will allow you to have pretty good function. So, physical therapy is often helpful in patients early on in this process.
Melanie: And, what's involved if you do have to do surgery?
Dr. Kavanagh: Yeah. The rotator cuff surgery itself is not a very big operation. A lot of the time nowadays we do it arthroscopically, so we're able to make some small incisions and then put a camera inside the shoulder and above the shoulder to look at the cuff tear and then put it back down to repair it, usually through something called “suture anchors”, which go into the bone and that allows us to retie the tendon back to where it belongs. So, the surgery itself is not a huge one. It's usually about an hour-and-a-half to two hours. It's a same-day procedure, so you go home afterwards. A lot of times, patients nowadays are getting blocks, which are the basically, anesthesiologists are putting some numbing medicine in the nerves that go down into the shoulder. That really helps us post-operatively control your pain. Really, the bad part about a rotator cuff repair is just the recovery itself is quite lengthy. So, for the first six weeks after a rotator cuff repair, you're going to be in a sling where you're only able to do what we call “passive range of motion”, and that means you're going to take the other arm to move the operative arm around. You can't actively fire your rotator cuff or use your rotator cuff muscles because that would put too much stress on the repair. So, that's for the first six weeks and then from week six to twelve, that's when we start active motion, meaning you're actively using your rotator cuff in your shoulder muscles. The therapists are going to help you kind of regain the range of motion and then, usually at three months on or twelve weeks, that's when you start strengthening. So, you start to use some bands and you start to use some weights to try to get the strength back in the rotator cuff. So, we have to protect you for a long period of time to allow this rotator cuff tendon to heal back down properly into the bone, so holding you back and protecting your repair will cause you to develop some stiffness and weakness. For most patients, I tell you that it takes about 6-12 months to completely recover from a rotator cuff surgery. At six months you'll be feeling pretty good, but from six months to twelve months, you'll definitely have more improvement, you'll get stronger and you'll have better flexibility.
Melanie: And then does scar tissue develop?
Dr. Kavanagh: Occasionally, it does, yes. Stiffness and weakness are kind of a normal complication from this surgery. That's why it's pretty important to be in physical therapy and not only to go to therapy but also to work on an exercise program at home. But, yes, occasionally patients will get a lot of scar tissue and kind of have limited mobility. I wouldn't say that this is very common but sometimes patients will need to go back in for a procedure called “a manipulation under anesthesia”. That's where we kind of break up some of the scar tissue when the patient's asleep so we're able to kind of move the shoulder without causing pain. But, again, that's not something that's kind of frequently done. It's for patients that develop stiffness in the shoulder that's not really responding to therapy.
Melanie: Is there any prevention?
Dr. Kavanagh: I would say that keeping the shoulder muscles active and in good shape is probably some prevention; if you can keep the muscles strong with lower-impact activities. Less weights, higher reps are things that are only going to put too much stress on the rotator cuff. We kind of want to keep everything strong, but we don't want to overdo it and cause too much stress, but overall keeping the shoulder healthy will keep it functioning more properly and, therefore, you'd be less likely to develop problems down the road from the rotator cuff itself.
Melanie: Dr. Kavanagh, in just the last few minutes, tell us about your team at Summit Medical Group.
Dr. Kavanagh: Sure. We're very excited that we're opening up a new orthopedic office in Warren, New Jersey, and it's an office that has a multi-specialty types of musculoskeletal doctors. We have some orthopedic surgeons who specialize in sports medicine and surgery. We have some physical medicine rehab doctors. We have some podiatry doctors, so we can really meet all the needs of our patients with pretty much any type of musculoskeletal problem. This office that's being opened is primarily all going to be all orthopedics. It’s really kind of directed at meeting all the needs of patients in this area.
Melanie: Thank you so much. What great information. You're listening to SMG Radio. For more information, you can go to summitmedicalgroup.com. That's summitmedicalgroup.com. This is Melanie Cole. Thanks so much for listening.