(light rock music)
- Welcome back to The Art of Medicine.
Let's take a look at the symptoms
of a rotator cuff tear
and how they affect your daily life.
- Primary symptom of a rotator cuff tear
is that of pain.
The location of the pain can vary,
but typically it's over the side
or lateral aspect of the shoulder.
Most patients come in and say,
"Doc, I have pain right here."
They don't understand that it's their rotator cuff.
Typically they think it should be
on the top of the shoulder,
but it's really over the side of the shoulder.
Commonly it occurs at night.
A lot of patients can't sleep on that shoulder at night,
or if they roll over in bed on that shoulder,
it just really, really hurts.
The second most common symptom is that of stiffness.
People notice that over time they just don't
have the range of motion that they had
in that shoulder years ago,
particularly in forward elevation.
They just can't lift that arm up like they used to.
Third most common symptom is that of weakness.
People notice they just don't have
the strength that they had five years ago.
They have difficulty doing very simple tasks
such as lifting a gallon of milk
and putting it in the fridge.
The most common type of tear is what we call
a degenerative type tear.
Between the ages of 50 and 55, as we age
the blood supply to the rotator cuff slows down.
There's an area in the cuff called the critical zone
that, because of the poor blood supply,
starts to tear off of the bone.
That's a degenerative type tear.
There's no trauma.
It's an insidious onset of pain,
and occurs very slowly over time.
The second most common type of tear
is that in the "weekend warrior",
or the overhead athlete, the swimmer,
the tennis player, raquetball,
guys that play softball.
Just with chronic overhead use of the shoulder
they're pinching that rotator cuff
underneath the acromion bone, and over the years
that cuff just starts to slowly tear.
Then the third most common type of tear
can occur in any age group.
It's with significant trauma,
say a motor vehicle accident or a significant fall.
There's so much force.
They fall on an outstretched arm,
and the cuff just tears off of the bone.
There are basically two types of rotator cuff tears,
and this is important,
because the treatment is very different.
A partial thickness tear is a tear in which
the cuff is not completely torn off of the bone.
I like to think of it in terms of a hundred page book.
If the rotator cuff is a hundred pages thick,
a partial thickness tear is when it's torn
through maybe 20 or 30 of the pages,
but it's not torn all the way through.
That's important because we don't typically operate
on partial thickness tears,
as opposed to a full-thickness tear.
A full-thickness tear is when your cuff's torn
through all hundred pages of that book.
It's completely torn through the full thickness.
It's torn off of the bone.
I tell people that's like having a hole in your pants.
That tear will just keep getting
bigger and bigger and bigger.
It will not heal on its own.
Until it gets large enough where you cannot
lift your arm over your head.
- Rosemary, you've had a shoulder injury,
and we want to now examine you.
But the most important thing is to ...
We've determined already, you've spoken to me,
and they told me that you hurt your shoulder
some time over the last couple of months.
The most important thing when we evaluate
a patient with rotator cuff problems
is to look and see where the pain is,
the range of motion of your shoulder,
and the strength of your shoulder.
The three things that we look for
with a patient with a rotator cuff problem,
is loss of motion, pain, and loss of strength.
The first thing I'd like to do
is just sort of examine your shoulder
and feel where it hurts.
A lot of people, patients with shoulder problems
have pain that radiates down their arm.
Sometimes it begins in a certain spot.
Sometimes it's even up here where
the collar bone and the shoulder blade come together.
and sometimes can even get into your neck.
Now, I'm going to just check your range of motion,
and you let me know if you have any pain.
This is flexion.
We've examined that.
External rotation, and internal rotation
I always evaluate up the spine.
I'm looking to look at a vertebral level.
We've measured her motion there and we'll record that.
Now I'm going to bring your arms out
and we're going to check some strength for you.
So bring your arms up here like this.
Sometimes this does elicit pain.
Let me know if it hurts.
Hold that nice and tight.
That's pretty good.
Then put your elbows by your side.
Push my hands away hard. Good.
Hold your hand right by your belly, hard and tight.
Hold it tight. Good.
Then bring your arm real close to yourself and hold it.
Good. Now, Rosemary, I want you to just
bring your arms up just like that as far as you can
and hold it high. Good. And then down.
I've examined your shoulder.
Any of my patients that have had pain for over a month,
I think that when they have some signs of weakness
it's important that we determine
why that weakness occurs.
One of the most common reasons for that weakness
is a rotator cuff tear.
That tear can be small. It can be large.
We really have no way of determining it
based on x-rays and physical exam.
We can get an idea of if there's a tear,
but we need that road map of your shoulder.
That's why I get an MRI for my patients
who've had that pain or weakness in their shoulder
for over a month or six weeks.
That will give us a good three-dimensional visualization
of that tendon and where it's attached.
- This is an x-ray of a left shoulder
in a patient that's been having
significant pain and weakness.
Let's look at the parts list.
First of all, this is the middle of the ball,
and this is the outer surface of the ball,
which is connected to the arm.
The ball sits into the socket,
which is the end of the shoulder blade.
On the end, or side of the ball,
there is a rope or tendon that pulls in this direction.
That tendon is called the rotator cuff tendon.
Above the tendon there are two bones
that form a joint.
This is the acromion bone.
This is the collar bone or clavicle.
Especially this acromion bone has a tendency
to form some rather large spurs that dig in,
and as in this patient, tear the rotator cuff tendon.
This is an MRI of that same patient with shoulder pain.
Let's go over the parts list.
The middle of the ball, the surface of the ball,
the ball connected to the arm.
The ball sitting in the socket.
Above the ball, those two bones that form a joint,
the acromion and the clavicle or collar bone.
And then, sitting between the top of the ball
and the undersurface of the acromion bone
is the rotator cuff.
A normal rotator cuff appears as a black band
in this space.
Here we see a white space that separates
two parts of the black band.
This white space indicates a rotator cuff tear.
(light rock music)