By Jacob D. Sams, MD
The shoulder joint is one of my favorite joints because of its complexity, yet simplicity. I always describe it as a golf ball on a golf tee. It is mostly supported by soft tissues. These soft tissues are responsible for the stability of the joint all while providing outstanding range of motion. The shoulder has a number of soft tissue structures that when injured or compromised, can create significant problems with both pain and function.
Starting with the most common, the rotator cuff is a group of muscles that act to hold the ball against the socket (glenoid) and allow for range of motion. Each muscle (supraspinatus, infraspinatus, subscapularis, and teres minor) all act upon the shoulder to produce movement (forward flexion, external rotation, and internal rotation). I feel like there are two main scenarios when I see rotator cuff pathology.
In this scenario, patients will say they just woke up one day with shoulder pain. They have had moderate level discomfort with painful range of motion. Range of motion tends to be maintained although certain positions can be much more painful than others.
These patients tend to wait a good 3-6 months or more before seeking care. In this scenario, my thought is that the rotator cuff has been strained or possibly partially torn. It is always my advice to try conservative measures to see if we can’t “fix” the problem without surgery. Treatments will be an injection of corticosteroids to see if we can decrease the amount of inflammation. I believe the injection is invaluable as a method to reset the shoulder so that we can be much more effective with physical therapy. One pitfall is that the injection might make the patient feel so good that they think nothing more is needed.
Unfortunately, without further optimizing the shoulder with physical therapy exercises to strengthen the rotator cuff and periscapular stabilizers, the positive effects of the steroid will be short lived. I prefer 6 weeks of physical therapy and home exercise program which most often will be dramatically helpful in alleviating the pain.
In this scenario, patients can be doing routine activities such as lifting something and they feel a “pop”. From that moment forward, shoulder range of motion is compromised. Pain is at least moderate to severe. Patients will say they can’t raise their arm.
In this setting, I am concerned for a full thickness tear to the rotator cuff. I think it is appropriate to take over the counter medications and give the shoulder a week or more to see if any improvement can be seen. If it can’t, I recommend an expedited evaluation with a shoulder expert.
Traumatic tears of the rotator cuff are best treated with early surgery. Surgery can fix the problem and patient outcomes are better than conservative measures in this scenario. It can be quite detrimental to wait months to seek care. If no early improvement can be seen in the shoulder following the injury, an MRI will often be ordered to better evaluate the structures of the shoulder and confirm the tear. In this setting, prolonged pre-operative physical therapy can waste valuable time.
Surgery to address rotator cuff pathology (partial or complete tears) is typically performed arthroscopically. This means poke holes around the shoulder. One portal is used to insert a camera while the other portals are used to pass instruments that can be used to repair the structures of the shoulder. This is a minimally invasive way to treat shoulder pathology.
Many of my patients come to me in complete fear of shoulder surgery because of horror stories from others. They are afraid of the pain. It is routine practice to use a nerve block between the neck and shoulder. This is a luxury that affords the patient with the opportunity to receive less anesthetic because they don’t feel their arm and secondly, they don’t have pain for 12-16 hours following the surgery. In that time, much of the initial swelling from the surgery can go down and patients are much happier with this approach to pain control.
They are able to use less narcotic pain medications which helps minimize confusion, constipation, and nausea. Many patients are able to quickly recognize a difference in the type of pain they are having with many saying that the pain they had before surgery is gone. They report the soreness they have is just from surgery itself. Arthroscopic shoulder surgery today is a safe and effective way of treating rotator cuff pathology and should not be something to fear.
Whenever I have someone who has a tear of the rotator cuff, I will tell them part 1 is for me to fix it. Part 2 is to let it heal. Unfortunately, when we fix the rotator cuff we are using small anchors and sutures to repair the torn tissue.
I need compliance from my patients to keep the rotator cuff still so that it can heal effectively. That is why we will use an immobilizer for 6 weeks following the surgery. I don’t want motion. I need healing.
Multiple scientific studies have been performed where patients who tried to use their arm too early had a much higher risk of re-tear compared to those who immobilized their arm for 6 weeks followed by guided physical therapy.
In conclusion, the shoulder is a fascinating joint that affords so much function. Treating shoulder problems is a significant part of my practice. I treat all aspects of shoulder pathology and rotator cuff pathology is one of the most frequent reasons patients are seen. I hope you find this information helpful in learning some common scenarios and themes as it relates to shoulder pain, rotator cuff injuries, shoulder surgery, and rehabilitation.
If you need help with your shoulder, please contact our shoulder experts at Decatur Orthopedic Center. It is our privilege to help you.
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