Question about my torn rotator cuff

[janet j]

I am 68 years old and had a fall skiing 2 years ago. After failing a trial of physical therapy for a rotator cuff tear, I saw a surgeon because I had pain above shoulder level, weakness, and incomplete motion. An Mri showed a tear of 2 tendons, and I had an arthroscopic rotator cuff repair 5 months later. I was doing okay, but over the past few months my pain is back, and I have alot of pain. I can still raise my arm above my shoulder. I was recently told that I have retorn the tendons. Even though I am 68, I am active and just hate thinking that my shoulder will hurt forever--and that nothing can be done.

My question is should I have the tendons fixed again? I have seen information on the internet about reverse type replacements. Is this something that might be necessary? Thanks for helping me figure out my options.

[mtomaino]

The fundamental question you raise has to do with how best to regain painfree function. Is it a second attempt at tendon repair, a tendon transfer--if the tear has become irreparable, or is it some type of shoulder replacement. The appropriate treatment strategy will be impacted by your exam (how high you can raise your arm and what your strength is?), what your x-ray looks like ( is your humeral head [the ball] centered on the glenoid [socket] or superiorly translated? Is there arthritis?), and by the health of your rotator cuff muscle (is there fatty infiltration or atrophy on MRI?).

In the March 2010 issue of the Journal of Bone and Joint Surgery (JBJS 2010; 92:590-598), Ken Yamaguchi and his co-authors from Washington University address the very title of this reply. They found that re-repair results in reliable pain relief and improvement in function in selected cases. Only half of the revision repairs were intact at 1 year follow-up, and patient age and the number of torn tendons were related to postoperative tendon integrity. Seventy percent of single tendon tears healed; results declined when both the supraspinatus and infraspinatus tendons were torn. They also noted that postoperative abduction strength and functional scores were better when tendon healing actually occurred--which is not surprising. The study was not designed to identify a particular age after which tendon healing is less likely, but it is well known that advanced age is a risk factor for poorer healing---probably more due to the status of the tendon that anything else.

Obviously what one wants to avoid is a revision cuff repair that is not going to work. By the same token, if a revision repair is likely to be successful---that is far better than living with pain or having a salvage procedure like a joint replacement--since the latter will require activity limitation down the road, in comparison.

At 68 years of age, if your cuff is clearly not repairable, and the pain is just not bearable, you may be a candidate for a joint replacement. A reverse type design will restore overhead activity quite effectively (see the video on the shoulder page of this website). But, if you can raise your arm above 90 degrees, a traditional hemiarthroplasty becomes an option---because, in this case, enough of a "force couple" exists to allow functional motion, and a reverse design is not required.

These are complicated issues---which is why it's important for you to understand the pros and cons of the various options. In summary, a particular treatment strategy for you will depend on a number of factors including your age, your activity expectations, your range of motion and strength, the x-ray, and the status of your cuff muscle.