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Shoulder and Elbow Program

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Minimally Invasive Rotator Cuff Repair Surgery: An Interview with Dr. James Dreese

In the following interview, University of Maryland Medical Center and Kernan Hospital orthopaedic surgeon and sports medicine specialist Dr. James Dreese answers questions about rotator cuff tears and minimally invasive rotator cuff repair surgery. This interview originally aired on the TV show Maryland Health Today. Click here to see the entire interview.

What are some of the most common types of shoulder injuries?

Rotator cuff injuries are very common. Rotator cuff injuries can vary from simple rotator cuff tendonitis, which is an inflammation of the tendon, to rotator cuff tears where the tendon has actually torn from the bone. Rotator cuff injuries are very common problems that we see in both younger and older patients. In younger patients we see primarily rotator cuff tendonitis from overuse activities such as throwing. In older patients we see tendonitis and rotator cuff tears.

What is a rotator cuff?

The rotator cuff is a series of four separate muscles in the shoulder joint that form tendons and insert onto the bone. The rotator cuff is made up of one muscle in the front of the shoulder as well as two muscles on top and one in the back. It’s really a combination of four separate muscles inside the shoulder joint. It is responsible for lifting the arm overhead and rotating the arm to the side.

One commonly seen injury is a rotator cuff tear. What is that?

A rotator cuff tear is an injury where the tendon/rotator cuff insertion tears from the bone. As a result of the tear from the bone rotator cuff tears do not have the potential to heal without intervention (surgery). Symptoms of rotator cuff tears include pain on the outer side of the arm and weakness in lifting the arm overhead. A common complaint of patients with rotator cuff tears is pain while trying to sleep at night.

In that case, is surgery usually required to repair a rotator cuff tear?

It typically is for rotator cuff tears. The primary problem that patients with rotator cuff tears suffer from is that they have pain as well as weakness in the shoulder. Those two problems can be debilitating for patients with rotator cuff tears. Because of the impaired blood supply, the rotator cuff doesn’t have the potential to heal itself when it’s completely torn. So in that situation, surgery is generally necessary. There are a small number of patients (typically older) whose demands are not as great who may do okay with a small rotator cuff tear. But in general, people who have rotator cuff tears don’t do very well without surgery because of the pain and the weakness that ensues.

How are rotator cuff tears diagnosed?

Rotator cuff tears are diagnosed with a number of different modalities. One is just based on a history where a patient may remember falling. They may remember that all of a sudden they awoke and they had intense pain in their shoulder, and they couldn’t lift their arm. The history is very important. In addition, we do X-rays to look at whether or not there are any changes that suggest a patient may have a rotator cuff tear. MRI is a very effective tool in diagnosing rotator cuff tears. Sometimes those results may not point to a definitive answer and arthroscopy of the shoulder may be necessary to make the definitive diagnosis.

Can shoulder surgery been done in a minimally invasive way?

We have developed techniques called arthroscopy where we can perform the surgery without making the larger incision which classically has been necessary to treat rotator cuff tears. During an arthroscopic rotator cuff repair, we insert a series of cannulas into the shoulder joint through a small number of incisions and then are able to visualize the rotator cuff tear and repair it. Sometimes the rotator cuff may tear within the tendon, where it’s repaired in a side-to-side fashion. Then the tendon where it’s torn from the bone will be repaired separately.

What are the advantages of arthroscopic surgery?

The advantages of arthroscopic surgery are smaller incisions, less disturbance of the normal shoulder musculature, and most likely less pain following surgery. Smaller incisions are cosmetically more appealing from a pain standpoint. A smaller incision causes less pain in the shoulder joint following surgery. The approach is less invasive and does not require splitting muscle layers in the same way that the traditional approach did. As a result the pain caused by splitting the muscle layers is decreased. The recovery time from the rotator cuff surgery is the same because it still takes the same amount of time for the tendon to heal back to the bone. But the advantages of arthroscopy are significant and have led to a lot of changes in the way we treat rotator cuff problems.

What type of anesthesia is used with this kind of surgery?

The surgery can be performed with general anesthesia. It can also be performed with regional anesthesia, where a block can be made into the nerves of the neck that make the arm go numb for a period of time, usually from 12 to 16 hours. That is more helpful for patients after the surgery in their pain control. Even when performed arthroscopically, rotator cuff surgery can be painful initially and the regional block can be very helpful in alleviating patient’s pain within that first 16-to-18 hour time frame.

Is this an outpatient procedure?

In general it’s performed as an outpatient procedure where a patient will arrive in the morning, have their surgery and go home the same day. If the surgery is more involved than what was previously thought or if patients have some underlying medical conditions, it may be necessary for them to spend the night in the hospital. But in general most patients can go home the same day as their surgery.

What is the recovery like?

The recovery occurs in a series of phases. The initial phase is immobilization, where patients wear a sling for three to four weeks to allow the tendon to start to heal on its own. At that time, a physical therapist is working with the patient to achieve restoration of range-of-motion. A physical therapist lifts the arm for the patient to avoid actively firing the muscle. Patients are not allowed to lift their arm on their own for the first 4-6 weeks following surgery because that would compromise the integrity of the repair. By 4-6 weeks following surgery the repair gains strength and the patient can begin to lift the arm and initiate some strengthening exercises. By 3 months following surgery most patients can lift between 5-10 pounds overhead. Strengthening exercises continue. By 6 months post-operatively most patients have regained approximately 80 percent of strength. It is important to continue with strengthening exercises after this time. Studies show that gains in strength continue over a two-year time period following surgery.

Is it important to keep moving the shoulder so the muscle stays in shape?

It is. It’s important to get some range of motion back so the shoulder doesn’t get too stiff. Anyone who’s been in a sling for a few weeks without moving their shoulder knows how stiff it can get. We want to make sure that doesn’t happen. After the four-week time frame we start to allow the patient to lift the arm with the assistance of a therapist and by about three months, they are able to lift the arm and do more aggressive strengthening exercises.

Why should patients consider coming to the University of Maryland Medical Center for rotator cuff surgery?

Rotator cuff surgery can be a complex procedure. In particular, arthroscopic rotator cuff surgery can be particularly demanding. It requires a skilled orthopaedic surgeon specifically trained in arthroscopic shoulder surgery, a dedicated team of anesthesia doctors to care for patients during the surgery, and a network of skilled physical therapists who understand the principles of a successful rehabilitation program. We are fortunate to have all of those resources available in the Sports Medicine program at the University of Maryland Medical Center. Our Sports Medicine physicians specialize in arthroscopic surgery of the shoulder and knee, providing world-class care to the Terps athletic teams at the University of Maryland. That experience, and the experience of caring for many of the areas other competitive and recreational athletes, has provided great insight and knowledge in performing arthroscopic surgery.

This page was last updated on: August 7, 2008.

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