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Rotator cuff injury question (Now with a 100% more correct diagnosis)

jungleroomxjungleroomx It's never too many graves, it's always not enough shovelsRegistered User regular
edited March 2012 in Help / Advice Forum
A little background:

About a year ago I was suffering from some pretty miserable shoulder pain. I underwent physical therapy and it started feeling better, until the exercises they gave me to do started causing pain. One by one I had to drop the exercises, and a few months later I was back at the docs because I couldn't lift my arm over my head.

Fast forward to now, and my MRI results on my shoulders have indicated complex tears in both shoulders (5 tears in the right, 3 in the left) and a labral cyst in my right shoulder that is pinching nerves.

What kind of treatment options am I going to have here? They want to send me back to physical therapy, but I can't imagine that working out a second time. Am I looking at surgery?

jungleroomx on

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  • WindburnWindburn Registered User regular
    A little background: I'm an orthopaedic surgery resident.

    First: the labral cyst. Labral cysts do not get large enough to pinch nerves, because there are no nerves that run within the shoulder joint and the labrum itself is not innervated. If you have the shoulder equivalent of a ganglion cyst (which is an outpouching and ballooning of the joint capsule), those can track toward the midline and compress on nerves that run around the scapula. The big question here is do you have any muscle atrophy on your scapula? If yes, then you definitely need surgery. If no, it's largely a symptomatic issue. If it's bothering you enough to offset the risks of surgery (see below), then have surgery. If not, then you should wait and try some conservative things first (like physical therapy) to see if it will improve that way.

    Second: How old are you? Age is a major factor in determining how to treat rotator cuff tears. If you are 15, you almost certainly need surgery. If you are 65, you almost certainly do not need surgery.

    Third: Not all rotator cuff tears are symptomatic. If we MRI'd everyone over the age of 40, 80% would have rotator cuff tears. Only about 10% of those are symptomatic. When your MRI report says that you have "complex tears in both shoulders (5 tears in the right, 3 in the left)" that sounds like a radiologist's report and not a surgeon's. First, the resolution of an MRI is not high enough to see tears in the rotator cuff unless they are full thickness with some retraction or joint fluid leak into the subacromial space. What we see instead with partial thickness tears is edema and inflammation in the muscle and tendon. This makes otherwise dark structures appear bright. So when a report says you have "3 tears in the left" I have to assume they mean 3 of the 4 rotator cuff muscles are torn. Of course, that means the "5 tears in the right" is non-sense, because there are only 4 rotator cuff muscles. In other words, don't take an MRI report as dogma. There are a lot of incidental findings, over-reads, and artifact on an MRI that must be correlated with your clinical exam before deciding if it's "real" or not.

    Fourth: What muscles are torn? Since you say that you can no longer lift your arm over your head, I'm going to assume that the supraspinatus is involved, which is very common. One of the etiologies of this is an acromial spur that impinges on the muscle with overhead activities. If you have such a spur, you need a subacromial decompression as well as a rotator cuff repair.

    Fifth: The truth is, unless you are a high-level athlete or an over-head laborer, you don't need your rotator cuff. The primary function of those 4 muscles are the keep the humeral head depressed, so it's not impinging on the acromion, and reduced against the glenoid (scapula side of the shoulder joint). There are other secondary muscles that can be strengthened to rebalance the shoulder and perform the function of the rotator cuff. THAT is the purpose of physical therapy. The shoulder hurts because those muscles are injured, but your body is still trying to fire them to stabilize your shoulder. If you can strengthen the secondary muscles, your body will stop firing the rotator cuff muscles and they will stop hurting as the inflammation subsides. The catch 22 is sometimes your shoulder hurts too much to do physical therapy. In this case, your doctor can try steroid injections into the shoulder or oral pain medicine. Neither are long term pain control solutions, but rather to control the pain enough to allow you to do physical therapy.

    Last: Surgery. The options here are open, mini-open, or arthroscopic. The "gold standard" is the open procedure where a larger incision is made, the shoulder is visualized from the outside only and the rotator cuff is repaired by hand. The arthroscopic procedure is much more common now and the outcomes are similar to the open procedure (may soon become the gold standard). Several small incisions (about the width of your finger nail) are made around the shoulder. Both the inside of the shoulder joint (an advantage over the open procedure) and the outside are visualized and repaired using a fiberoptic scope and long, thin instruments. The arthroscopic procedure has smaller scars and less post-op pain with a slightly higher repair failure rate compared to the open procedure. The mini-open tries to combine the best of both procedures by visualizing the joint with a scope, but repairing the rotator cuff through a larger incision (thus decreasing the failure risk). However, the mini-open has a much higher infection rate. We're not sure why, but it is quite clear in the literature, so most people don't do this anymore.

    The main risks of surgery are post-op pain, chronic pain, infection (potentially catastrophic for your shoulder and entire body; surgery should NEVER be undertaken lightly), allergic reaction, iatrogenic injury (damage to your joint from the instruments used during surgery), bleeding, temporary or permanent nerve damage, and repair failure requiring repeat surgery. After your procedure, you will be in a sling for several weeks, followed by months of physical therapy. Don't think that surgery is a quick fix and that it will spare you from having to do physical therapy. You can have a beautiful repair and if you don't hold up your side of the equation, you will end up with a painful, stiff shoulder that is much worse functionally than what you have now.

    I hope this helped.

  • mtsmts Dr. Robot King Registered User regular
    just saving this space for when i have time to actually post something. since i had my larbum repaired in 09 to fix a pretty substantial tear

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  • jungleroomxjungleroomx It's never too many graves, it's always not enough shovels Registered User regular
    Windburn wrote:

    All kinds of great info!

    First, I'd like to thank you for all the time it probably took you to type that out. It gave me a lot to chew on.

    However, after my followup with my doc, I have a few corrections to my original post!

    First some missing info:

    1. I'm 31 years old
    2. I'm in the US Army, so while I may not be a star athlete or overhead laborer, full use of my arms is pretty much a must.
    3. My shoulder injury is highly symptomatic: For the past few months I've been woken up to a throbbing, constant dull/burning ache in my shoulder if I don't "sleep right". My shoulder has locked up and felt like it had "slipped out of joint" quite a few times.

    Now, upon seeing my doctor this morning, I find out that the over-the-phone consult was given by a nurse... and she was incorrect on quite a few things:

    The "tears" she mentioned were actually arthritic spots in my shoudlers.

    I do not have a tear on the rotator cuff muscles, but an unknown type complex SLAP tear on the labrum. The cyst has grown from the tear itself, and I've had it for a while (He estimates at least as long as my first visit to the doctors office last summer from my symptoms), although he insists it's virtually impossible to date an injury like this with other than general statuses (New or old).

    I did not get the name of the ligament he was telling me about, but also it appears that one of my ligaments is showing laxity.

    I've been told that within the military that physical therapy is required for every injury, regardless of type, and I'll have to go through 4-6 weeks of physical therapy which is going to be then followed up by another MRI, and then surgical consults. It's come to my attention from the doc that the chances of my recovery through therapy is basically nil, and I should pretty much consider this entire procedure a formality... and was also advised to not injure myself further if at all possible. He could not say for sure what kind of surgery it would be, but he shared with me that he's surprised my arm can even rotate around and that the injury itself is "impressive" and should not be taken lightly.

  • LewieP's MummyLewieP's Mummy Registered User regular
    I'm not an orthopaedic surgery resident, I'm just LewieP's Mummy, but I've learnt some new words from Windburn, thank you!.

    I damaged my left rotator cuff when I fell - slightly complicated by having Poland's Syndrome on that side, which also means the muscles, bones and nerves are wonky. I also developed bone spurs as a result of the fall, and after months of physio, was in pain - I couldn't raise my left arm high enough to turn a light switch off, couldn't carry anything on that arm or shoulder, it made me quite miserable. I had arthroscopic surgery to repair the tear and to file off the bone spurs that one muscle was catching on and causing lots of the pain. I had my arm in a sling for a while, had lots of physio, and its as right as rain now. I have several tiny scars round my shoulder, that are now 3 years later almost invisible, and as much use of my arm/shoulder as I had before.

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  • mtsmts Dr. Robot King Registered User regular
    So a SLAP tear just refers to the location of the tear (s). I believe that means the tear is on the topside of the joint. Anyway. My tear was basically from 3'o'clock to 9 o'clock front to back, and jihad fraying of the supraspinatus and need the subacromial decompression. All in all 6 anchors were put in.

    At the point of my surgery there was no way pt would have helped and I had pain all the.time.(sleeping, walking,pretty much everything).

    Keep in mind the military is a.lot different in terms of what gets done and when, but if my doctor said they were going to go right to.open, I would look for another surgeon. Arthroscopic is the way to go and should be the first option. If that fails, then open it up.

    As for the mri, see if they will do a contrast one. They would inject dye into the joint and that highlights any tears.
    Following surgery, expect pain and swellingcin the joint and arm for a week or so. Make sure you make your range of motion exercises your new job. I was back in a sling for 6 weeks. And I was back. To full Rom by 3-4 months post op. And then back in my kayak by 5-6 months.

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