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Summarized
by Dr. Scott Haig
November 6, 2006
Dr.
Scott Haig is an Assistant
Clinical Professor of
Orthopedic Surgery at
Columbia University College
of Physicians and Surgeons.
He has a private practice in
the New York City area. He
writes helpful articles on
health topics for TIME
magazine, and we reproduce
one of them here. Robert
Griffith, Editor.
Rotator
Cuffs: the Next Big Thing
Tearing
and what's called
"maceration" of
the rotator cuff are the
most common causes of
chronic shoulder pain in
adult Americans. I find them
and other shoulder problems
fascinating; this strangely
tendon-wrapped joint has
kept my professional
interest level amazingly
high for the 22 years that
I've been doing orthopedics.
If it's hard to find a
comfortable place for your
arms when you're in bed at
night, you're probably
feeling rotator cuff pain.
Cuff discomfort is usually a
"night pain" in
its early phases. Ball
throwing and racquet sports
become uncomfortable but you
can still manage to play -
it's the pain later on,
especially at night that
first brings the patients
in. Overhead activities like
putting up books or stacking
dishes on a high shelf give
the same hard-to-pinpoint
shoulder and upper-arm pain.
Cuff patients start avoiding
movements that make them
exert force at a distance
from their bodies; fanning a
blanket out over a bed,
putting a child in a car
seat, opening a window.
There are, of course, some
devoted athletes, who first
complain that the pain and
weakness is affecting their
squash or tennis game.
What
the heck is a rotator cuff
anyway and why is it always
tearing?
The
shoulder is set up
differently than any other
joint. Whereas your hip can
be likened to a ball in a
socket (a cantaloupe in a
bowler hat seems more apt)
your shoulder, bone-wise is
like a basketball on a
tea-saucer. It has very
little mechanical stability
by virtue of its bony
architecture. In other
words, it would be always
dislocated were it not for
the soft tissues that
surround it. Your shoulder
moves more widely and in
more different ways than any
other joint in the body, yet
it's very strong. The design
feature that enables these
feats is the cuff - three
flat tendons that blend
together like a thick
leathery hood covering a
bald man's head - the head
in this case being the
smooth cartilage-covered
ball at the top of the
humerus or arm bone. The
cuff's unique tendons apply
muscular forces which
stabilize and greatly
strengthen the movement of
your arm. (Remember tendons
are the attachments of
muscles to bone - they
pull).
So
for the many sufferers the
cuff gets into trouble
primarily because it doesn't
have enough room; it gets
rubbed on, abraded, sanded
down, weakened and
eventually torn by the
undersurface of the bone
(the acromion) that you feel
when you put your hand on
top of your shoulder. This
mechanism, called
"impingement," is
the initial culprit in most
cases. It's probably not
"the old high school
football injury" coming
back to plague you in your
old age. Even folks who say
their cuff was torn in a
recent injury probably had a
cuff that was already
weakened by this "bone
spur" phenomenon. So
give that old coach a break.
Surgery
for rotator cuff injury
One
way or another a lot more
patients are coming to their
orthopedist complaining
about shoulder pain. The
arthroscopic repair is a
great operation because it
fixes the problem securely
but leaves only three or
four little cuts on your
shoulder. Each is a mere
centimeter long, they don't
hurt very much (usually -
there are exceptions) and
you can go home from the
hospital the same day. Most
patients are off pain
medicines and back to work
in two days. It's my
favorite case and they're my
happiest patients. They tell
their friends that they're
out of pain. More
convincingly, they beat
their friends at squash and
tennis. This seems to be
what gets people into my
office and it's why
arthroscopic cuff repairs
are so "hot" right
now - word of mouth
referral. With all due
respect to the medical
marketing folks - it ain't
them. I can't read a
magazine, see a movie or
even be put on hold on the
telephone without being
blasted by medical
advertising. We're
desensitized, immune to it -
after all, how many
"best doctors" can
there be? But your
brother-in-law kicking you
up and down the court and
then getting a good night's
sleep afterward? That brings
in patients.
The
growth in shoulder surgery
and rehabilitation has been
remarkable and, as you would
imagine, quite profitable
for the medical industry. I
have been doing my repairs
arthroscopically for about
seven years and I hope I
never have to go back to the
old way. The only reason for
this would be financial. All
this innovation is,
predictably, rather
expensive. I used $20 worth
of suture in 1999 when I did
the repair open (through a
regular surgical incision,
looking at the tissues
directly with my eyes, not
on a TV screen). The
bio-absorbable suture
anchors, pumps, cannulas and
all the other little
throw-away doodads that make
my arthroscopic repair
possible typically cost over
$1200 per case. The
arthroscopic method probably
accounts for about half of
the rotator cuff surgeries
now being done in the U.S.
Every year more surgeons are
switching over to the all-arthroscopic
technique. This is a great
example of patient-driven
medicine; we are doing a
more expensive, technically
more difficult procedure
primarily for short term
comfort and patient
acceptance.
The
eventual results from the
more traditional open
surgery are every bit as
good in terms of pain relief
(95% get better) and
improved strength (75%
better) as arthroscopic
repairs.
The
final caveat if your
shoulder hurts and you're
thinking about an
arthroscopic repair is that
the ultimate strength of the
repair is not achieved until
at least 6 months after the
surgery - and many studies
suggest 18 months is a more
correct figure. So,
sore-shouldered Americans,
please bear in mind: this
too costs a lot and takes
longer than you might think.
(Thanks
to TIME magazine for their
tacit permission to
reproduce this article)
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