Rotator Cuff Injury Specialist
Are you an athlete who participates in sports that involve throwing overhead? If so, you may be at risk of sustaining a rotator cuff tear. A rotator cuff tear is typically caused by a fall, sports injury or degeneration. Rotator cuff injury specialist, Dr. Robert Boykin provides diagnosis and both surgical and nonsurgical treatment options for patients in Asheville who have suffered a rotator cuff injury. Contact Dr. Boykin’s team today!
Anatomy of the Rotator Cuff
The shoulder joint is a highly mobile joint that allows the largest range of motion of any joint in the body. The power for the motion of the shoulder is provided by the muscles around the joint. A group of four muscles collectively known as the “rotator cuff” provide strength for movement in addition to stability by compressing the ball into the socket. These muscles are named as follows:
- Supraspinatus
- Infraspinatus
- Subscapularis
- Teres minor
Pathology of a Rotator Cuff Tear
They contribute to the motions of forward flexion (bringing arm in front of a patient), abduction (bringing arm out to the side), internal rotation (reaching behind the back), and external rotation (reaching behind the head). If any of these structures are damaged or injured, a loss of mobility of the shoulder joint may occur, accompanied by severe pain. Injuries to the rotator cuff are very common in athletes due to overuse of the shoulder and acute trauma. These tears are also commonly seen as a patient ages. Shoulder specialist Dr. Robert Boykin focuses on the treatment of rotator cuff injuries for patients in Asheville, Arden, Fletcher and surrounding North Carolina communities. The tears can be grouped into two categories:
- Acute tear– When the rotator cuff becomes injured due to a fall, sports related trauma, or an accident such as a motor vehicle collision.
- Degenerative tear – As a patient ages, so do the muscles and tendons surrounding the joints. Over time these become weaker, increasing the risk of a rotator tear even without major trauma.
The spectrum of rotator cuff disease progresses from tendonitis (inflammation) to partial tearing to full thickness tearing.
Symptoms of a Rotator Cuff Tear
Symptoms associated with a rotator cuff injury are a direct result of the damage to the muscles surrounding the shoulder and the inflammation that accompanies it. Some symptoms associated with a rotator cuff injury are:
- Chronic aching pain
- Pain at night
- Inability to lift the arm and perform normal daily activities
- Limited range of motion
How to Diagnose a Rotator Cuff Injury
In order to determine the severity and thus the proper treatment of a rotator cuff injury, Dr. Boykin will perform a complete examination of the shoulder by assessing range of motion, strength, and muscle loss in addition to reviewing X-rays. Specific tests for rotator cuff injuries include the Jobe test, Lift off sign, Belly press test, and the Hornblower sign. After the initial examination, Dr. Boykin will most likely order a MRI to confirm the diagnosis, visualize the extent of injury, and determine the quality of the muscle.
Following a diagnosis of the injury, Dr. Boykin will present a patent with their treatment options. The best treatment option for a rotator cuff injury is dependent upon the severity and nature of the injury. The ultimate goal is to reduce the inflammation and pain associated with the tear and restore function to the shoulder. Rotator cuff tendonitis is first treated with non-operative measures including rest, physical therapy, anti-inflammatory medications, and potentially an injection of corticosteroids. Partial thickness tears, small full thickness tears, and chronic tears may also be first treated with conservative measures.
Treatment Options for a Rotator Cuff Injury
If non-surgical treatment methods do not prove to be beneficial or in the cases of acute full thickness tears Dr. Boykin may recommend surgery. Dr. Boykin will present the options and discuss which surgical treatment will benefit the patient by taking into account the age, lifestyle, and goals of the patient.
If a decision for surgery is made, arthroscopic surgery for the rotator cuff will likely be performed through a number of small incisions through which Dr. Boykin will insert a camera and special surgical instruments in order to repair the tearing. Arthroscopic shoulder surgery allows a quicker recovery and less post-operative pain than open techniques.
In more severe cases, Dr. Boykin will may need to make an open incision and will repair the damage to the shoulder. This surgery is performed if the damage requires a more extensive or different type of repair than can be accomplished through an arthroscopic approach.
Massive rotator cuff repair FAQ
What is a massive rotator cuff repair?
A massive rotator cuff repair is a surgical treatment to repair the torn tendon(s) that make up a rotator cuff. A massive rotator cuff tear occurs when at least two of the four rotator cuff tendons have torn away from or have retracted from the attachment site on the humerus. Tears of this nature are usually 5 cm or greater. Dr. Robert Boykin has extensive experience in repairing massive rotator cuff tears.
Can a massive rotator cuff tear be repaired?
Many massive rotator cuff tears are able to be repaired using standard arthroscopic surgery techniques. There is a better chance of repair is the tear is acute – the longer amount of time that passes the more difficult the repair will become. Careful visualization, techniques for release of tissue and mobilization of the torn tendon, and modern implants for fixation lead to a high rate of success in a majority of patients.
At times these tears can be a challenge and sometimes they cannot be repaired. If the rotator cuff muscle is no longer functioning, due to atrophy from a long-standing tear, the repair may not be possible. Over time the normal muscle of the rotator cuff can become weak, which is not reversible.
In addition, if the tendon tissue is damaged or if it has degenerated, the tendon can be frayed, weak or pulled back (retracted). In these cases, a massive rotator cuff tear at times cannot be repaired because the normal elasticity of the tendon is lost, and sutures would not hold the tendon to its anchoring spot.
Muscles damaged from atrophy or extensive degeneration/retraction usually do not have good results from a standard rotator cuff repair. In cases where the muscle is viable and the tendon can be mobilized (moved) back partially Dr. Boykin may recommend augmentation of the repair with a “patch” consisting of either allograft tissue (from a donor) or other types of collagen tissue. This can reinforce the damaged rotator cuff tissue and assist in healing. In cases where the native tendon is extensively atrophied and immobile then Dr. Boykin may recommend a newer arthroscopic procedure called a superior capsular reconstruction or proceeding directly to a reverse total shoulder replacement.
Do I need surgery to repair a massive rotator cuff tear?
Even with massive rotator cuff tears, some patients find good results with non-surgical treatments. This may include rest, physical therapy or injections. Dr. Boykin can advise patients on the proper treatment for their specific type of massive rotator cuff tear.
What is the repair technique for a massive rotator cuff repair?
Dr. Boykin prefers an arthroscopic approach for the vast majority of massive rotator cuff tears. Arthroscopic repair involves small incisions in which a small camera and small instruments are utilized to operate inside the joint. The procedure is performed as an outpatient surgery with regional and general anesthesia.
During the surgery, the torn rotator cuff tendons are pulled back onto the bone and secured with sutures. Over time the tendon will reattach to the bone and the patient will regain strength of the shoulder joint through physical therapy.
What is the rehabilitation of a massive rotator cuff repair?
A successful arthroscopic rotator cuff repair is highly dependent on the patient’s willingness to follow the advice and recovery guidelines given by Dr. Boykin and his team. Generally, passive motion exercises begin at 2 weeks after surgery with active motion after about 6-8 weeks. Strengthening commences at 10-12 weeks and progresses per protocol.
What is the recovery time from a massive rotator cuff repair?
Recovery time will vary based on the extent of tendon damage, age and health of the patient and actual shoulder surgery performed. Typical tears can take approximately six months to reach full recovery.
What are the four rotator cuff muscles?
Supraspinatus: This holds the upper arm bone (humerus) in place and keeps the upper arm stable. This muscle helps lift the arm in forward flexion. This is the most commonly torn tendon of the rotator cuff.
Infraspinatus: This is the main external rotator of the shoulder.
Teres Minor: This is the smallest rotator cuff muscle and assists with external rotation and lateral motion. This tendon is rarely torn.
Subscapularis: This large muscle runs in front of the shoulder joint and provides force for internal rotation of the shoulder. Tears of the tendon are commonly associated with injuries to the biceps tendon including subluxation (where the biceps tendon slips into the tear).
*The term “tendon” describes the very end of a muscle that thickens where it attaches to bone.
Rotator cuff repair FAQ
How do I know if I have damaged my rotator cuff?
Most rotator cuff tears occur from a fall or an acute injury or may be caused by normal age-related wear and tear. If the rotator cuff is damaged, pain in the front of the shoulder that radiates down the side of the arm is a typical symptom. Overhead activities, such as throwing, lifting or reaching may make the pain worse. Patients also notice weakness of the arm and have difficulty with routine activities such as combing their hair or reaching behind their back. Another common complain is nighttime pain while sleeping.
How painful is a torn rotator cuff?
Rotator cuff tears that happen over time from wear and tear or slow degeneration of the tendon do not often have sudden symptoms. Symptoms from this type of tear include:
- Pain at night or when resting, especially if lying on the affected shoulder
- Pain when lifting and lowering the arm or with specific movements
- Weakness when lifting or rotating the arm
- Crepitus or crackling sensation when moving the shoulder in certain positions
Rotator cuff tears that happen suddenly from an acute injury can have an immediate, intense pain, accompanied by a snapping sensation and immediate weakness in the arm.
Do rotator cuff tears heal on their own?
This is a subject of great debate and extensive study. Many partial thickness tears (and some full thickness tears) may be treated without surgery. This includes rest, activity modification, non-steroidal anti-inflammatory medications, steroid injections, strengthening exercises and physical therapy. Larger full thickness tears have been shown to not reliably heal on their own and tend to get larger over time therefore for active patients surgery is recommended to restore function, reduce pain, and prevent the tear from becoming bigger and more debilitating. In addition, large tears that are left alone tend to retract further over time away from their attachment site (making repair more difficult) and the muscles that are not connected may atrophy (shrink) and become replaced by fat. When this occurs repair may not be advisable.
Is rotator cuff surgery considered major surgery?
Most rotator cuff surgeries are done on an out-patient basis and are categorized as a “major” surgery. That being said there are risks associated with any surgical procedure and these will be discussed with the patient by Dr. Boykin and his team.
How long does it take to recover from torn rotator cuff surgery?
Recovery time will vary based on the extent of tendon damage, age and health of the patient and actual shoulder surgery performed. Typical tears can take six months to reach full recovery.
How do I relieve pain associated with a rotator cuff tear?
Symptoms from a rotator cuff tear can be treated with ice, placed at the front of the shoulder, where the pain is felt. Rest and discontinuation of the activities that cause further shoulder pain will also help. Dr. Boykin may prescribe non-steroidal anti-inflammatory medication (NSAIDS) or administer a steroid shot into the shoulder which can also relieve pain.
Will a cortisone shot help a torn rotator cuff?
Studies have shown that cortisone injections can be incredibly helpful at limiting the acute inflammation of in the setting of rotator cuff pathology and allowing the patient to begin therapy. Many factors influence the decision as to whether surgery is recommended vs. an injection of physical therapy and Dr. Boykin will discuss these with you after the diagnosis is made. It is important to follow Dr. Boykin’s physical therapy recommendations, even if the shoulder feels better after an injection. While the cortisone can help keep shoulder inflammation down, physical therapy will help prevent a recurrence of symptoms.
For additional resources regarding rotator cuff injuries, or for information on other shoulder injuries and treatment approaches, please contact the office of shoulder specialist, Dr. Robert Boykin, orthopedic shoulder, knee, and hip surgeon serving Asheville, Arden, Fletcher and surrounding North Carolina communities.