Rotator cuff tears are a common cause of pain and disability in adults. The rotator cuff is made up of four muscles and their tendons that combine to form a "cuff" over the head of the humerus. The four muscles include the supraspinatus, infraspinatus, subscapularis and teres minor. The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint. Most tears occur in the supraspinatus, but other portions of the rotator cuff can be involved.

Rotator cuff tears usually occur due to falling, lifting or repetitive overhead arm activities (reaching up to stack shelves, throwing a baseball and working overhead, for example). A specific shoulder injury is not always definable. Sometimes patients can get these tears with gradual wear and tear - like balding and grey hair, they just happen.

Although they're most common in people over the age of 40, rotator cuff tears may occur in younger patients who suffer from acute trauma or are involved in repetitive overhead work or sports activity. A cuff tear may also occur in connection with another injury to the shoulder, such as a fracture or dislocation.

Our practice performs several hundred outpatient arthroscopic rotator cuff repairs a year. We've stayed at the fore of advances in this procedure by regularly participating in and lecturing at symposiums around the country, conducting basic science and clinical research and maintaining a close relationship with orthopedic equipment manufacturers. Here are some of the keys to our success with this procedure.

Why we prefer arthroscopic repair
In general, three approaches are available for surgical repair: arthroscopic, mini-open and formal open rotator cuff repairs. We perform the majority of our repairs using arthroscopic techniques. The continuously evolving instrumentation systems available let us do more complex and larger rotator cuff repairs arthroscopically than ever before. This method minimizes muscle injury and post-operative pain while improving post-operative mobilization and cosmesis.

The procedure is done using approximately four 5mm incisions around the shoulder. First, we visualize the tear and confirm the correlation with the pre-operative imaging study (usually an MRI). We then shave any symptomatic bone spurs and begin our repair using small bioabsorbable screw-in anchors and sutures. Next, we mobilize the rotator cuff back to where it was originally attached on the bone, securely fasten it by passing the sutures through the cuff and tie it down. The procedure can take one to two hours, depending on the extent of the tear.

Although the skill of the surgeon is critical, two other factors in the operating room optimize our efficiency and outcomes, help keep our surgical times short and minimize risk for complications.

• Organization and standardization. We work as efficiently as possible by standardizing everything we do. We use the same OR, the same surgical team and the same anesthesia team. Each patient is positioned in the same way - seated - to allow for safe management of the airway and optimal access to the surgical site. We also standardize the placement and setup of equipment in each case.
• Anesthesia. Improvements in anesthesia and pain control have been absolutely critical to the success of these procedures. Although some surgeons will use an interscalene nerve block and sedation, we prefer general anesthesia supplemented with an interscalene block because it lets us optimize perioperative pain control and ensure patient comfort and airway safety throughout the surgery. The interscalene block provides pain control for 12 to 16 hours after surgery.

Recovery and rehabilitation
Immediately post-operatively, we immobilize the shoulder in a sling. As long as their pain is controlled, they're not nauseous and they're able to urinate, we discharge patients two to three hours after surgery. We'll never compromise safety and will admit patients overnight if there's any concern about their overall condition. We call patients at home the same day of surgery to check on them and review any questions they may have about their post-op instructions.

We see our patients at day five or six after surgery to review our surgical findings. Recent studies have shown that post-operative immobilization allows for more secure healing of the rotator cuff, we'll routinely immobilize patients' arms for four to six weeks in a sling. However, we cater our post-operative regimen individually on a case-by-case basis. We treat each patient as an individual and consider the whole person when deciding upon treatment and rehabilitation.

It generally takes about four to five months for a patient to regain full, unrestricted use of the arm. Therapy progresses from gentle stretching to strengthening in a graduated manner. Return to sports takes a minimum of four to six months to allow for maximum healing and rehabilitation.

Future advances in rotator cuff surgery are focusing on the use of tissue engineering in an attempt to repair traditionally irreparable rotator cuff tears. Rotator cuff tears are currently labeled as irreparable tendon tears if they involve significant muscle belly atrophy, tendon degradation and retraction or demonstrate poor healing ability after attempted previous surgical repair. We as clinician-scientists continue to work on surgical solutions for these scenarios; however, reliable alternatives for these clinical cases remain several years away.