Rotator Cuffs: the Next Big Thing

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Do you have what Donald Rumsfeld has? A lot of folks do. 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. So when, in the middle of doing an arthroscopic rotator cuff repair this morning, my trusty assistant Dave told me about Don Rumsfeld's repair, I knew I had to get the plain truth out to our readership — as soon as possible.

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

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If it's hard to find a comfortable place for your arms when you're in bed at night, you're probably feeling Don's 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, as Mr. Rumsfeld did, 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 including Rumsfeld (and, lest there be jealousy on the other side of the aisle, John Kerry had his cuff done during the last presidential election) 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.

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, Mr. Rumsfeld (and our other sore-shouldered Americans), please bear in mind: this too costs a lot and takes longer than you might think.