‘Appropriate’ Treatment for Rotator Cuff Tears

The most common shoulder injuries treated among older adults in the United States are rotator cuff tears, according to information published this summer by the National Center for Biotechnology Information, a research branch of the National Library of Medicine. The American Academy of Orthopaedic Surgeons (AAOS) estimates that nearly 2 million Americans visit their doctor each year because of a torn rotator cuff. Tears can be the result of trauma or occur over time as the tendons that make up the rotator cuff wear down, often due to age.

Orthopedic Surgeon
Derek Papp, M.D.

Recently, Miami Orthopedics & Sports Medicine InstituteOrthopedic Surgeons DerekPapp, M.D., and GautamYagnik, M.D., were tapped by the AAOS to help develop the “AppropriateUse Criteria for the Management of Rotator Cuff Pathology,” released in lateSeptember. This document will guide doctors’ and other orthopedic surgeons’treatment of rotator cuff tears.

What is the Rotator Cuff?

The rotator cuff consists of four tendons that cover thehead of the upper arm bone, or humerus, connecting it to the shoulder blade. Itenables the raising and lowering movement and rotation of the upper arm. Whenthese tendons are injured from sudden trauma or from repetitive overheadmovement, such as from painting, playing baseball, golf, tennis or swimming,they can detach partially or wholly from the bone, Dr. Papp says. They also canfray or degenerate slowly over time due to aging, leading to similardetachments.

Risk Factors for Rotator Cuff Tears

In addition to repetitive movements from an occupation orsports and advancing age, the American Academy of Orthopaedic Surgeons cites a diminishingblood supply to the rotator cuff tendons as individuals age as anothercontributing factor to tears. Without adequate blood supply, the body’s abilityto repair itself is greatly reduced, increasing the risk of a tear. The Academyalso notes that bone spurs, caused by overgrowth of bones, can rub on thetendons of the rotator cuff – a condition called shoulder impingement – weakeningthe tendons and making them more likely to tear.

Symptoms of a Rotator Cuff Tear

A partial or complete rotator cuff tear that develops overtime often causes varying levels of pain – from none at all to significant pain,especially at night when resting on the injured shoulder. This varied pain may alsocome with lifting, lowering or rotating the arm and may be accompanied byweakness and a crackling sensation, referred to as crepitus. If the tearresults suddenly, as from a fall or trauma, the pain is often intense after asnapping or popping sensation and noticeable weakness.

Orthopedic Surgeon
Gautam Yagnik, M.D.

Non-Surgical Treatment of a Rotator Cuff Tear

Dr. Papp says that the guidelines he and Dr. Yagnik helpeddevelop for the AAOS recommend starting with conservative treatments. This isthe treatment path they both follow in their practice at the Institute.  

“In general, rotator cuff tears do not heal on their own,” Dr.Papp said, “but we can help the pain improve with a variety of treatments,including physical therapy, anti-inflammatory oral medications and differentinjections, such as cortisone to minimize swelling and platelet-richplasma, or PRP, therapy to speed up the healing process.” 

While for some patients these non-operative treatments willprovide lasting relief, Dr. Papp admits that other patients may eventually requiresurgery if their pain increases and their movement or quality of lifediminishes. Some active people, he says, elect for surgical treatment no matterwhat their age to ensure the best results for them.

Surgery to Repair a Rotator Cuff

Dr. Papp and Dr. Yagnik, who both specialize in shouldersurgery, along with their sports medicine colleagues at Miami Orthopedics &Sports Medicine Institute, have performed thousands of rotator cuff repairprocedures, and patients do well after their surgery.

“I generally perform arthroscopic rotator cuff repair forthe vast majority of my patients,” Dr. Papp said.  This minimally invasive approach is performedthrough small incisions that avoid trauma to surrounding tissues and minimizebleeding and the chance for complications. The arthroscopic approach, Dr. Pappnotes, also means less time in the hospital and a quicker return to activity.

“For my patients with tears that have failed prior surgical repairor who have massive chronic tears, I’ll sometimes treat with a reverse totalshoulder replacement because of the quick recovery,” he said. This procedureinvolves attaching a replacement shoulder socket onto the top of the upper arm boneand a metal ball is secured to the natural shoulder socket. Dr. Papp says thisnewer approach allows different muscles to move the arm, which may be necessarywith a tear that has been problematic for some time.     

Another procedure that Dr. Yagnik successfully performs on otherwiseirreparable rotator cuff tears is an arthroscopic superior capsularreconstruction, which uses a graft to stabilize and restore function of theshoulder.

Dr. Papp says that each of these procedures, as well as many others, were considered when he and Dr. Yagnik were choosing the most appropriate treatment options for the guidelines.

‘Pioneers’ of New Surgical Techniques

“We created guidelines for just about every type of tear,”he said. “We looked at tiny tears, massive tears, acute tears and chronic tearsin both young and older patients. We also considered the best treatments forhealthy patients versus those with multiple medical problems.”

Dr. Papp and Dr. Yagnik, both members of the AAOS, werechosen for this panel because of their surgical experience and participationwith the Arthroscopy Association ofNorth America (AANA) and the AmericanOrthopaedic Society for Sports Medicine (AOSSM),respectively. They and their orthopedic colleagues at Miami Orthopedics & SportsMedicine Institute are pioneers in the development of new surgical techniquesfor shouldersurgery.

Rotator Cuff Research at the Institute

Thedoctors and the rest of their colleagues at Miami Orthopedics & SportsMedicine Institute are also actively studying the clinical outcomes of rotatorcuff surgery in an effort to improve patient outcomes. This past year, Dr.Yagnik presented his experience with rotator cuff tear progression inprofessional contact athletes at both the NFL and NHL Team Physician SocietyMeetings. Dr. Yagnik hopes that the information obtained from studying these rare,but potentially career-threatening, injuries in elite athletes can be used toenhance treatments and repair techniques that will benefit all patients.

“It was great to be a part of this panel,” Dr. Papp said.“We like to be sure we do the right things as surgeons, and this process helpedvalidate our approach and highlight our success. One of the best parts about myjob involves getting people back able to work and play without pain.”

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