A rotator cuff tear is a common cause of pain and disability among adults. According to the American academy of orthopedic surgeons, close to 2 million people in the United States went to their doctors because of a rotator cuff problem.
A torn rotator cuff can weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.
Rotator cuff injuries are also very common sport related injuries, especially in sports that require repetitive overhead arm motions.
Listen in as Dr. Andrew Erwteman discusses Rotator Cuff Tears and the treatments available at Temecula Valley Hospital.
Selected Podcast
Rotator Cuff Tear Treatment Options
Featured Speaker:
Andrew Erwteman, MD
Dr. Andrew Erwteman is an orthopedic surgeon in Murrieta, California. He received his medical degree from New York Medical College. He is a member of the medical staff at Temecula Valley Hospital. Transcription:
Rotator Cuff Tear Treatment Options
Melanie Cole (Host): A rotator cuff tear is a common cause of pain and disability among adults. Close to 2 million people in the United States go to their doctors because of rotator cuff problems. My guess today is Dr. Andrew Erwteman. He’s an orthopedic surgeon with a subspecialty in sports medicine and a member of the medical staff at Temecula Valley Hospital. Welcome to the show, Dr. Erwteman. Please tell us a little physiology. What’s the rotator cuff?
Dr. Andrew Erwteman (Guest): Thanks. Good morning. So, first, I guess I’ll start by describing briefly what the shoulder joint is like. It’s a ball and socket joint. The ball is the humeral head and the socket is something called the “glenoid” which is your shoulder blade. The rotator cuff is really a synthesis of the capsule that surrounds this joint with some tendons embedded within it. The tendons are of some specific muscles four in total called the subscapularis, the supraspinatus, infraspinatus, and teres minor. Really, the goal of these muscles is, as you move your arm in space, is to center the humeral head or the ball into this shell or socket. They also provide some strength for moving your arm in various different directions.
Melanie: Because the shoulder is such a complicated joint with so many movements, Dr. Erwteman, tell us a little bit about how easily or what causes some of these issues and tears in the rotator cuff.
Dr. Erwteman: So, typically, when you think about a tear in the rotator cuff, you break it down into two categories. There can be an acute tear, which could be from a traumatic situation such as a fall, maybe with an outstretched arm trying to break your fall; or a heavy object that’s falling that you catch with an outstretched arm where it just overloads the tendon and it can tear, either in its midsubstance where the muscle is or where the tendon attaches to the muscle, or sometimes it can pull right off the bone where it attaches on the humeral head. More commonly, these tears end up being more of a chronic tear that’s attritional in nature. It’s degenerative over time and, as you get older, actually it’s a fairly common thing that happens.
Melanie: So, what are some of the symptoms? Because this is so common, especially in the older population, it seems like all of them have one rotator cuff tear or another. What are some of those red flags that would signal that this is what’s going on?
Dr. Erwteman: Well, if you have the acute form of the injury, you may have a trauma as I described above and then you may notice that there’s some pain and weakness in the arm, difficulty raising the arm up and that’s one big red flag. For the more chronic cuff tears, it becomes a lot harder because it’s often on a spectrum where it starts to bother you, sometimes only positionally or when you’re trying to raise your arm up in the air, maybe to reach a glass in the cabinet. Then, it tends to progress to the point of where maybe you’ll start having pain more often or pain waking you up at night in the shoulder. Then, in its most extreme form, if the tear becomes severe, you may notice that you’re having a lot of trouble now even raising your arm up in the air and sometimes it’s not as much pain that holds you back at that point, but it’s just pure weakness. Of course, it’s associated with some pain. You may also start to notice a crunching sound called “crepitus” when you move your arm around but there are a number of tears that are actually asymptomatic as well.
Melanie: So, Dr. Erwteman, do these tears heal themselves?
Dr. Erwteman: So, it’s really hard for the tear to heal itself for a variety of reasons. Number one, the attritional tears, the tissue itself is sort of degenerative in nature. The quality of tissue is not quite as good and the blood supply is not quite as good. So, those degenerative tears, they’re really not going to heal on their own and the acute tears, they often don’t either and the reason why, a lot of times, is because there is some tension in the entire muscle/tendon unit which can cause the tendon to pull away from its attachment site a little bit. So, it would be hard for it to heal back down sometimes without some intervention. That doesn’t always mean that it’s going to become symptomatic or create disability.
Melanie: So, what is the first line of defense if someone comes to you with this shoulder pain and they have trouble putting on their jacket or they’re feeling that nighttime pain when they lie on their side? What’s the first thing you do for them?
Dr. Erwteman: So, the first line of defense is always non-surgical for patients like this unless it’s an acute tear, especially in a younger person who had a perfect shoulder and now they have this trauma and all of a sudden they have pain and weakness moving their arm and you do some work-up and find that there’s a big rotator cuff tear. Those kinds of tears, you want to try and get to and repair sooner rather than later because that’s good tissue and the likelihood of that healing and restoring good function to their shoulder is much greater compared to leaving it alone and waiting. For the more degenerative tears, there’s really no harm in starting with non-surgical therapy and trying a combination of either Tylenol or anti-inflammatory medication. Physical therapy is very helpful for helping to restore range of motion as well as to compensate for the tendon that has torn. As I said, we have 4 rotator cuff tendons. If one is torn, either partially or fully, you still have others that are still attached that we can strengthen and attempt to compensate for function that’s been lost with physical therapy. Another intervention that you can try which is a little bit more invasive is an injection, often with corticosteroid into the shoulder. This can help you initially, especially in a patient who has a lot of pain but the long-term benefits are uncertain with injections of corticosteroid. The effects on tissue area also a bit uncertain, so repeated injections is really a practice that’s discouraged.
Melanie: How many is repeated injections that you say, “That’s enough. Now we need to look at other interventions”
Dr. Erwteman: So, a number that’s often thrown around is 3-4 injections per year for any joint. I’m not sure there’s great science behind that recommendation. I’ve never found anyone who’s been able to explain where that came from. We do know that some of the steroid medication remains in the joint because if we end up doing an arthroscopic surgery, we can see some of the crystallized medications floating around in the joint or covering the surfaces of the cartilage but for a rotator cuff tear, if you’ve tried conservative management, including the anti-inflammatories, physical therapy and you have an injection for pain. Then, you come back a few months later and the injection wore off, you’re still having pain, you’re just not making any progress, you can try another injection and continue with the therapy exercises but if it’s still not working at that point, chances of it working with a third injection, to me, seems slim to none. So, you can consider it if your life situation is not good for more advanced or surgical type treatment but I would recommend stopping, probably, after that second injection.
Melanie: So, then, tell us what’s involved with surgical intervention. If it gets to the point where these symptoms have lasted a while, they’ve tried the steroid injections and the other non-surgical interventions; what do you tell them about surgery for the rotator cuff?
Dr. Erwteman: So, if you have something called a “partial thickness tear” where the tear is not complete, so the tendon is not completely torn away from bone but its attachment site is partially torn off the bone and the pain just will not get better. That’s the main thing that we would aim to treat is the pain and it will not get better with any of conservative measures that we mentioned, sometimes we can do an arthroscopic debridement, which is a term that means sort of cleaning up the torn end of the tendon and, hopefully, stimulating some healing or scarring over a dead site. Sometimes, smoothing out some of the bone above the rotator cuff where a lot of the wear and tear may be occurring on the rotator cuff from the overlying bursa and bone and sometimes that helps people quite a bit. If you have a full thickness tear so that the tear has pulled all the way off the bone, then entails attempting to repair the rotator cuff tendon back down to the bone oftentimes using something called an “anchor” which either comes in a plastic form or a metal form and it has some sutures attached to it and you try to put that right in the footprint of the tendon and then you use the suture to tie it into the tendon and then advance that tendon back down to its native footprint. That’s really what the repair is all about: trying to restore the anatomy.
Melanie: What’s it like for the patient, doctor, after they’ve had surgery for their rotator cuff? Is there scar tissue that develops? Do they get range of motion back?
Dr. Erwteman: So, there’s definitely scar tissue that develops because that’s how our body heals in most instances. So, we don’t perfectly regenerate tissue like a salamander would for their tail. If scar tissue develops, that’s what strengthens some of the repair. What you can expect afterward is, typically, patients are in a sling for at least 4-6 weeks. I used to be a physical therapist and when I was doing that, it seemed like people were coming out of their slings a little bit earlier. I think the trend now is that people are staying in slings a little bit longer because we’re nervous that these tendons are going to re-tear. So, we try to give them more time to heal. It’s typically at least 4-6 weeks in a sling; if it’s a really massive tear, sometimes even longer. Then, you can expect to do some gentle range of motion exercises earlier on but certainly no strengthening for at least 3-4 months. Patients tend to, if they have decent range of motion before surgery, they do tend to get very functional range of motion back. Sometimes, there’s a little bit less than they had before but they tend to get a very functional range of motion back, meaning they can do most of the things that they want to do. What I often tell people, and this is probably something I got from a combination of reading the literature and some of the orthopedic surgeons that I’ve trained with, is that roughly the rotator cuff repair will heal at about 10% a month. There’s no great science behind this but it’s just an estimate. Everyone heals at a different rate but that means that, really, it can take up to 10 months to a year for this really to heal massively and patients have to be very careful in this time period.
Melanie: Do you have any advice for the golfers out there and the weekend warriors in possibly preventing rotator cuff issues?
Dr. Erwteman: Well, it’s hard to prevent from the standpoint of tissue quality over time but what you can do is, obviously, a good warm-up and stretching is always important and for the weekend warrior, your muscles can be trained to deal with a certain amount of stress and if you gradually train your muscles to do that and gradually increase the volume of your training or the intensity, then they handle it a little bit better than someone who is a weekend warrior and goes out and really overdoes it compared to what their normal activity is and then really overloads all of their muscles and tendons. So, just like all muscles and tendons in our bodies, staying in shape and training and not just going out and overdoing it is really probably the mainstay of prevention.
Melanie: In just the last few minutes, what should people with rotator cuff tears think about when they’re seeking care?
Dr. Erwteman: Well, number one, they should think about probably a good word of mouth referral to somebody is always a useful way to find somebody to take care of your rotator cuff. A lot of times, if it’s not a traumatic tear like I mentioned before, a lot of the times for those chronic tears, there’s no harm in attempting a non-surgical treatment as long as they understand that it may not get better from that and if they choose to take the non-operative route, there is a chance that it can become more symptomatic or the tear can progress. So, they should probably have some good follow-up. I think knowing that, work with someone who has that same concept of how to treat it is probably a good start.
Melanie: Why should they come to Temecula Valley Hospital for their care?
Dr. Erwteman: Well, I think there are certainly good orthopedic surgeons that can handle this rotator cuff problem and help these patients just as well as anybody else in the area and for the patients that live in the area, there’s certainly not reason for them to travel outside of the Temecula Valley for care.
Melanie: Thank you so much for being with us today, doctor. It’s really great information. You’re listening to TVH Doc Talk with Temecula Valley Hospital. For more information, you can go to www.temeculavalleyhospital.com. That’s www.temeculavalleyhospital.com. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.
Rotator Cuff Tear Treatment Options
Melanie Cole (Host): A rotator cuff tear is a common cause of pain and disability among adults. Close to 2 million people in the United States go to their doctors because of rotator cuff problems. My guess today is Dr. Andrew Erwteman. He’s an orthopedic surgeon with a subspecialty in sports medicine and a member of the medical staff at Temecula Valley Hospital. Welcome to the show, Dr. Erwteman. Please tell us a little physiology. What’s the rotator cuff?
Dr. Andrew Erwteman (Guest): Thanks. Good morning. So, first, I guess I’ll start by describing briefly what the shoulder joint is like. It’s a ball and socket joint. The ball is the humeral head and the socket is something called the “glenoid” which is your shoulder blade. The rotator cuff is really a synthesis of the capsule that surrounds this joint with some tendons embedded within it. The tendons are of some specific muscles four in total called the subscapularis, the supraspinatus, infraspinatus, and teres minor. Really, the goal of these muscles is, as you move your arm in space, is to center the humeral head or the ball into this shell or socket. They also provide some strength for moving your arm in various different directions.
Melanie: Because the shoulder is such a complicated joint with so many movements, Dr. Erwteman, tell us a little bit about how easily or what causes some of these issues and tears in the rotator cuff.
Dr. Erwteman: So, typically, when you think about a tear in the rotator cuff, you break it down into two categories. There can be an acute tear, which could be from a traumatic situation such as a fall, maybe with an outstretched arm trying to break your fall; or a heavy object that’s falling that you catch with an outstretched arm where it just overloads the tendon and it can tear, either in its midsubstance where the muscle is or where the tendon attaches to the muscle, or sometimes it can pull right off the bone where it attaches on the humeral head. More commonly, these tears end up being more of a chronic tear that’s attritional in nature. It’s degenerative over time and, as you get older, actually it’s a fairly common thing that happens.
Melanie: So, what are some of the symptoms? Because this is so common, especially in the older population, it seems like all of them have one rotator cuff tear or another. What are some of those red flags that would signal that this is what’s going on?
Dr. Erwteman: Well, if you have the acute form of the injury, you may have a trauma as I described above and then you may notice that there’s some pain and weakness in the arm, difficulty raising the arm up and that’s one big red flag. For the more chronic cuff tears, it becomes a lot harder because it’s often on a spectrum where it starts to bother you, sometimes only positionally or when you’re trying to raise your arm up in the air, maybe to reach a glass in the cabinet. Then, it tends to progress to the point of where maybe you’ll start having pain more often or pain waking you up at night in the shoulder. Then, in its most extreme form, if the tear becomes severe, you may notice that you’re having a lot of trouble now even raising your arm up in the air and sometimes it’s not as much pain that holds you back at that point, but it’s just pure weakness. Of course, it’s associated with some pain. You may also start to notice a crunching sound called “crepitus” when you move your arm around but there are a number of tears that are actually asymptomatic as well.
Melanie: So, Dr. Erwteman, do these tears heal themselves?
Dr. Erwteman: So, it’s really hard for the tear to heal itself for a variety of reasons. Number one, the attritional tears, the tissue itself is sort of degenerative in nature. The quality of tissue is not quite as good and the blood supply is not quite as good. So, those degenerative tears, they’re really not going to heal on their own and the acute tears, they often don’t either and the reason why, a lot of times, is because there is some tension in the entire muscle/tendon unit which can cause the tendon to pull away from its attachment site a little bit. So, it would be hard for it to heal back down sometimes without some intervention. That doesn’t always mean that it’s going to become symptomatic or create disability.
Melanie: So, what is the first line of defense if someone comes to you with this shoulder pain and they have trouble putting on their jacket or they’re feeling that nighttime pain when they lie on their side? What’s the first thing you do for them?
Dr. Erwteman: So, the first line of defense is always non-surgical for patients like this unless it’s an acute tear, especially in a younger person who had a perfect shoulder and now they have this trauma and all of a sudden they have pain and weakness moving their arm and you do some work-up and find that there’s a big rotator cuff tear. Those kinds of tears, you want to try and get to and repair sooner rather than later because that’s good tissue and the likelihood of that healing and restoring good function to their shoulder is much greater compared to leaving it alone and waiting. For the more degenerative tears, there’s really no harm in starting with non-surgical therapy and trying a combination of either Tylenol or anti-inflammatory medication. Physical therapy is very helpful for helping to restore range of motion as well as to compensate for the tendon that has torn. As I said, we have 4 rotator cuff tendons. If one is torn, either partially or fully, you still have others that are still attached that we can strengthen and attempt to compensate for function that’s been lost with physical therapy. Another intervention that you can try which is a little bit more invasive is an injection, often with corticosteroid into the shoulder. This can help you initially, especially in a patient who has a lot of pain but the long-term benefits are uncertain with injections of corticosteroid. The effects on tissue area also a bit uncertain, so repeated injections is really a practice that’s discouraged.
Melanie: How many is repeated injections that you say, “That’s enough. Now we need to look at other interventions”
Dr. Erwteman: So, a number that’s often thrown around is 3-4 injections per year for any joint. I’m not sure there’s great science behind that recommendation. I’ve never found anyone who’s been able to explain where that came from. We do know that some of the steroid medication remains in the joint because if we end up doing an arthroscopic surgery, we can see some of the crystallized medications floating around in the joint or covering the surfaces of the cartilage but for a rotator cuff tear, if you’ve tried conservative management, including the anti-inflammatories, physical therapy and you have an injection for pain. Then, you come back a few months later and the injection wore off, you’re still having pain, you’re just not making any progress, you can try another injection and continue with the therapy exercises but if it’s still not working at that point, chances of it working with a third injection, to me, seems slim to none. So, you can consider it if your life situation is not good for more advanced or surgical type treatment but I would recommend stopping, probably, after that second injection.
Melanie: So, then, tell us what’s involved with surgical intervention. If it gets to the point where these symptoms have lasted a while, they’ve tried the steroid injections and the other non-surgical interventions; what do you tell them about surgery for the rotator cuff?
Dr. Erwteman: So, if you have something called a “partial thickness tear” where the tear is not complete, so the tendon is not completely torn away from bone but its attachment site is partially torn off the bone and the pain just will not get better. That’s the main thing that we would aim to treat is the pain and it will not get better with any of conservative measures that we mentioned, sometimes we can do an arthroscopic debridement, which is a term that means sort of cleaning up the torn end of the tendon and, hopefully, stimulating some healing or scarring over a dead site. Sometimes, smoothing out some of the bone above the rotator cuff where a lot of the wear and tear may be occurring on the rotator cuff from the overlying bursa and bone and sometimes that helps people quite a bit. If you have a full thickness tear so that the tear has pulled all the way off the bone, then entails attempting to repair the rotator cuff tendon back down to the bone oftentimes using something called an “anchor” which either comes in a plastic form or a metal form and it has some sutures attached to it and you try to put that right in the footprint of the tendon and then you use the suture to tie it into the tendon and then advance that tendon back down to its native footprint. That’s really what the repair is all about: trying to restore the anatomy.
Melanie: What’s it like for the patient, doctor, after they’ve had surgery for their rotator cuff? Is there scar tissue that develops? Do they get range of motion back?
Dr. Erwteman: So, there’s definitely scar tissue that develops because that’s how our body heals in most instances. So, we don’t perfectly regenerate tissue like a salamander would for their tail. If scar tissue develops, that’s what strengthens some of the repair. What you can expect afterward is, typically, patients are in a sling for at least 4-6 weeks. I used to be a physical therapist and when I was doing that, it seemed like people were coming out of their slings a little bit earlier. I think the trend now is that people are staying in slings a little bit longer because we’re nervous that these tendons are going to re-tear. So, we try to give them more time to heal. It’s typically at least 4-6 weeks in a sling; if it’s a really massive tear, sometimes even longer. Then, you can expect to do some gentle range of motion exercises earlier on but certainly no strengthening for at least 3-4 months. Patients tend to, if they have decent range of motion before surgery, they do tend to get very functional range of motion back. Sometimes, there’s a little bit less than they had before but they tend to get a very functional range of motion back, meaning they can do most of the things that they want to do. What I often tell people, and this is probably something I got from a combination of reading the literature and some of the orthopedic surgeons that I’ve trained with, is that roughly the rotator cuff repair will heal at about 10% a month. There’s no great science behind this but it’s just an estimate. Everyone heals at a different rate but that means that, really, it can take up to 10 months to a year for this really to heal massively and patients have to be very careful in this time period.
Melanie: Do you have any advice for the golfers out there and the weekend warriors in possibly preventing rotator cuff issues?
Dr. Erwteman: Well, it’s hard to prevent from the standpoint of tissue quality over time but what you can do is, obviously, a good warm-up and stretching is always important and for the weekend warrior, your muscles can be trained to deal with a certain amount of stress and if you gradually train your muscles to do that and gradually increase the volume of your training or the intensity, then they handle it a little bit better than someone who is a weekend warrior and goes out and really overdoes it compared to what their normal activity is and then really overloads all of their muscles and tendons. So, just like all muscles and tendons in our bodies, staying in shape and training and not just going out and overdoing it is really probably the mainstay of prevention.
Melanie: In just the last few minutes, what should people with rotator cuff tears think about when they’re seeking care?
Dr. Erwteman: Well, number one, they should think about probably a good word of mouth referral to somebody is always a useful way to find somebody to take care of your rotator cuff. A lot of times, if it’s not a traumatic tear like I mentioned before, a lot of the times for those chronic tears, there’s no harm in attempting a non-surgical treatment as long as they understand that it may not get better from that and if they choose to take the non-operative route, there is a chance that it can become more symptomatic or the tear can progress. So, they should probably have some good follow-up. I think knowing that, work with someone who has that same concept of how to treat it is probably a good start.
Melanie: Why should they come to Temecula Valley Hospital for their care?
Dr. Erwteman: Well, I think there are certainly good orthopedic surgeons that can handle this rotator cuff problem and help these patients just as well as anybody else in the area and for the patients that live in the area, there’s certainly not reason for them to travel outside of the Temecula Valley for care.
Melanie: Thank you so much for being with us today, doctor. It’s really great information. You’re listening to TVH Doc Talk with Temecula Valley Hospital. For more information, you can go to www.temeculavalleyhospital.com. That’s www.temeculavalleyhospital.com. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.