Will a torn rotator cuff require surgery?

The answer to this question depends on the condition of the other shoulder muscles and the age of the patient. Many older patients have no symptoms with a rotator cuff tear and continue to function without pain or disability. In the younger age groups, particularly when tears are caused by a sudden injury, early surgery is generally recommended because rotator cuff tears have been shown to become larger and more difficult to repair over time.

What is Impingement Syndrome?

Impingement syndrome is an older term used to describe rotator cuff inflammation from rubbing on the roof of the shoulder (known as the “acromion”). Current thinking is that rotator cuff pain can also be caused by lack of blood supply and especially from gradual tearing of the tendon. Other terms commonly used to describe rotator cuff inflammation are tendonitis and bursitis of the shoulder. The typical symptoms are pain in the lateral shoulder especially at night or with overhead use of the arm.

Is physical therapy likely to make rotator cuff inflammation better?

Physical therapy is the mainstay of treatment for rotator pain. The vast majority of patients improve with therapy and oral anti-inflammatory medication. Strong rotator cuff muscles can relieve impingement symptoms by exerting a downward force on the humeral head, opening up the space available under the acromion. Tears of the rotator cuff cannot be resolved with physical therapy, but the healthier the rotator cuff is, the less likely it is that surgery will be required. If surgery on a torn rotator cuff is required, it is almost always performed arthroscopically through small incisions in an outpatient surgical center.

What are Ligament and Labral tears of the shoulder?

The shoulder joint itself consists of a shallow socket called the “glenoid” and a relatively spherical head attached to the arm bone (the “humerous”). A group of ligaments attach the humeral head to the glenoid where they form a thickened rim called the labrum. These ligaments can tear from trauma such as a dislocation or an accident that twists or pulls on the arm. Usually, the ligament tears off of the glenoid, pulling off the labrum with it. That is why ligament tears are commonly called labral tears, the most common of which is called a “Bankart Lesion”. The long head of the biceps attaches to the superior labrum and tears in this area are sometimes called SLAP lesions (Superior Labrum Anterior Superior).

Can Labral and Ligament Tears heal without Surgery?

Yes they can. Labral tears in patients over 40 years old will usually heal well with time and appropriate physical therapy. In younger patients, small labral tears that are not causing complete dislocations of the shoulder can also heal with rehabilitation. Patients younger than 25 who have had a shoulder dislocation or especially multiple dislocations have a very high chance of continuing to dislocate, causing further damage to the joint. Rehabilitation can be tried in these cases but arthroscopic ligament repair is often necessary and is very successful.

What is a knee “Torn Cartilage”?

“Torn Cartilage” is the layman’s term for a tear in one of the cushioning bearings inside the knee, technically called the meniscus. The meniscus matches the curved surface of the thigh side of the knee (the femoral condyle) to the flat surface of the leg side of the knee (the tibial plateau). These bearings have a poor blood supply so that when they tear, they usually do not heal well. In some cases, arthroscopic surgery is needed to remove the torn section or repair the meniscus in order to relieve the symptoms of pain, clicking or giving way. In older patients, a torn meniscus can often be part of an overall degenerative arthritic process and surgery on this type of a tear is usually not recommended since arthroscopic surgery cannot fix the arthitic component of the problem (see Arthritis section below).

Can the ACL heal by itself?

Some knee ligaments, such as the medial collateral ligament (MCL), heal reliably without surgery. Some partially torn ACLs may also heal without surgery. However, a complete tear of the ACL rarely heals. This is due to the amount of energy involved in the injury, the lack of blood supply, and the interior location of the ACL. The torn ACL may scar back to the intact PCL within the knee, but this rarely returns stability to the knee. In fact, even when the ends of a torn ligament are sutured together (called a primary or direct repair), the ligament does not reliably heal. Therefore, surgery for a complete ACL tear (an ACL reconstruction) involves replacing the ACL with other tissue (a graft).

Is surgery always needed for an ACL tear?

Surgery is not required for all ACL injuries. Partial tears, in which a physical examination shows a relatively stable knee, may be treated with bracing and rehabilitation. Some patients with complete ACL tears do not need reconstruction. These are typically older patients with lower physical activity, who do not participate in pivoting and cutting activities. In active, symptomatic patients, ACL reconstruction can restore stability to the knee, allowing for a return to high activity levels. ACL reconstruction is almost always performed arthroscopically. It is important that reconstruction be done in the most anatomically correct method possible.

What is Arthritis?

Arthritis is the wearing away of the surface of a joint, known as articular cartilage. This causes inflammation, swelling, pain and loss of function. The most common type of arthritis is osteoarthritis, which is from trauma or wear and tear over time. Osteoarthritis may also be genetically passed down in families. The other major category is rheumatoid and rheumatoid like arthritis, which is caused by an auto immune mechanism. Rheumatoid types of arthritis are best treated initially non-surgically by doctors who specialize in this condition, called Rheumatologists. In patients with very localized damage to the articular surface of the joint, these areas can be repaired surgically with a cartilage graft. This can be very successful and prevent further progression.

What is the best treatment of arthritis?

Most commonly, patients have a more diffuse form of joint surface damage. Symptoms can almost always be reduced without surgery. The most important initial treatment for lower extremity arthritis is weight control since a joint will experience 4-5 times the load of a person’s weight when walking. Certain foods can reduce inflammation, such as nuts and dark green vegetables. Fried foods and foods with white flour and refined sugars increase inflammation and should be avoided. We have also found glucosamine and chondroitin supplements to be helpful in some patients. Low impact exercise can increase flexibility and improve strength. Anti-inflammatory medicines such as ibuprofen or naproxen can relieve pain but should be used for short periods only, especially in patients with any gastrointestinal problems, high blood pressure or a cardiac history as it can make these conditions worse. Cortisone injection into a joint can be effective in reducing pain and inflammation but should not be used frequently because, in the long run, they can make the arthritis worse.

Recently, visco supplementation shots have been introduced for knee arthritis. These are believed to improve the cushioning effect of joint fluid. We have found them effective in many patients with mild to moderate osteoarthritis.

What is a joint replacement and who needs one?

Joint replacements are surgical procedures that involve the removal of the degenerated surface of a joint and resurfacing it with an implant. Joint replacement of the knee and hip is the most common. Shoulder replacement is also very commonly performed in our center. Continued improvements in implant design have made them more anatomically correct and have led to more normal function. Recent advances in materials should make these replacements last longer. Joint replacement is indicated in patients who no longer can control their pain and loss of function through diet, exercise, therapy and medication. Although a doctor can determine whether a joint replacement is appropriate, the final decision to have a joint replacement is always made by the patient.

What is “Direct Anterior” hip replacement?

Hip replacement has been performed with excellent success for decades. The most common approach in the past has been to perform the operation from a posterior approach, which involves splitting the gluteus maximus muscle and detaching the deep rotational muscles from the hip. This necessitates a pillow between the legs and special precautions to prevent dislocation for the first month or two after surgery. The direct anterior approach to the hip is a newly developed way to replace the hip from the front, which does not require any muscles to be split or detached. Patients who have surgery performed in this way do not need a pillow between the legs after surgery, have to take fewer precautions in using their new hip and typically can walk without a limp within 2 weeks.

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