‘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.

Recently, Miami Orthopedics & Sports Medicine Institute Orthopedic Surgeons Derek Papp, M.D., and Gautam Yagnik, M.D., were tapped by the AAOS to help develop the “Appropriate Use Criteria for the Management of Rotator Cuff Pathology,” released in late September. 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 the head of the upper arm bone, or humerus, connecting it to the shoulder blade. It enables the raising and lowering movement and rotation of the upper arm. When these tendons are injured from sudden trauma or from repetitive overhead movement, such as from painting, playing baseball, golf, tennis or swimming, they can detach partially or wholly from the bone, Dr. Papp says. They also can fray or degenerate slowly over time due to aging, leading to similar detachments.

Risk Factors for Rotator Cuff Tears

In addition to repetitive movements from an occupation or sports and advancing age, the American Academy of Orthopaedic Surgeons cites a diminishing blood supply to the rotator cuff tendons as individuals age as another contributing factor to tears. Without adequate blood supply, the body’s ability to repair itself is greatly reduced, increasing the risk of a tear. The Academy also notes that bone spurs, caused by overgrowth of bones, can rub on the tendons of the rotator cuff – a condition called shoulder impingement – weakening the 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 also come with lifting, lowering or rotating the arm and may be accompanied by weakness and a crackling sensation, referred to as crepitus. If the tear results suddenly, as from a fall or trauma, the pain is often intense after a snapping or popping sensation and noticeable weakness.

Non-Surgical Treatment of a Rotator Cuff Tear

Dr. Papp says that the guidelines he and Dr. Yagnik helped develop for the AAOS recommend starting with conservative treatments. This is the 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 different injections, such as cortisone to minimize swelling and platelet-rich plasma, or PRP, therapy to speed up the healing process.” 

While for some patients these non-operative treatments will provide lasting relief, Dr. Papp admits that other patients may eventually require surgery if their pain increases and their movement or quality of life diminishes. Some active people, he says, elect for surgical treatment no matter what their age to ensure the best results for them.

Surgery to Repair a Rotator Cuff

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

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

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

Another procedure that Dr. Yagnik successfully performs on otherwise irreparable rotator cuff tears is an arthroscopic superior capsular reconstruction, which uses a graft to stabilize and restore function of the shoulder.

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 tears in both young and older patients. We also considered the best treatments for healthy patients versus those with multiple medical problems.”

Dr. Papp and Dr. Yagnik, both members of the AAOS, were chosen for this panel because of their surgical experience and participation with the Arthroscopy Association of North America (AANA) and the American Orthopaedic Society for Sports Medicine (AOSSM),respectively. They and their orthopedic colleagues at Miami Orthopedics & Sports Medicine Institute are pioneers in the development of new surgical techniques for shoulder surgery.

Rotator Cuff Research at the Institute

The doctors and the rest of their colleagues at Miami Orthopedics & Sports Medicine Institute are also actively studying the clinical outcomes of rotator cuff surgery in an effort to improve patient outcomes. This past year, Dr. Yagnik presented his experience with rotator cuff tear progression in professional contact athletes at both the NFL and NHL Team Physician Society Meetings. Dr. Yagnik hopes that the information obtained from studying these rare, but potentially career-threatening, injuries in elite athletes can be used to enhance 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 helped validate our approach and highlight our success. One of the best parts about my job involves getting people back able to work and play without pain.”