P&S Journal: Spring 1994, Vol.14, No.2
Rotator Cuff Problems: Research, Diagnosis, and Treatment
By Robin Eisner
Rotating your arm back, down, forward, and up in a circle requires an enormous interplay of muscles, tendons, and bones in the shoulder. Athletes, such as swimmers and baseball and tennis players, who lose their ability to perform this overhead motion cannot continue their sport. Similarly, a worker impaired from reaching and lifting can lose a job.
While some patients with shoulder problems can get by with anti-inflammatory drugs or phys- ical therapy, others need surgical treatment. Regardless of the severity of the problem, patients seeking the latest in research, diagnosis, and treatment of shoulder ailments visit Dr. Louis Bigliani, associate professor of orthopedic surgery, and his colleagues, Drs. Evan Hector and Roger Pollack, assistant professors of orthopedic surgery, on the shoulder service of the Department of Orthopedic Surgery. Besides beginning the first dedicated shoulder service in the world, CPMC also started the first shoulder fellowship in the world for orthopedic residents.
Renowned for expertise in all aspects of the shoulder, the shoulder service is recognized in particular for solving problems in the shoulder's rotator cuff, where tendons from four muscles-the subscapularis, the supraspinatus, the infraspinatus, and the teres minor-blend together to insert on the humerus, the upper arm bone. When tendons detach from the humerus, uplifting movement is impaired and surgical modifications in the cuff and tendon reattachment become necessary to restore cuff function. "Problems in the rotator cuff are the reason for a significant portion of shoulder surgeries," says Dr. Bigliani. "Around 30-40 percent of my practice involves surgery of the rotator cuff."
P&S surgeons have dealt with rotator cuff ailments since the 1930s, says Dr. Bigliani, whose predecessor, Dr. Charles Neer, now director emeritus of the shoulder service, was one of the most inventive surgeons in this area. "He pioneered so many techniques," says Dr. Bigliani, "that the shoulder service has always been years ahead in innovative ideas and treatment options."
Dr. Neer made a significant contribution to shoulder surgery when he found that spurs on the acromion, a front- and side-facing portion of the scapula (the bone in the upper back that forms part of the shoulder), can cause rotator cuff tears. He developed surgical techniques that remove the spurs from the acromion. He also was involved in creating methods that reattach torn tendons to the humerus.
Dr. Bigliani has extended Dr. Neer's work in diagnosing and treating rotator cuff disease. Using X-rays, dissection, and analysis of the shoulder muscles and bones of 200 cadavers, Dr. Bigliani found that 15 percent to 25 percent of the cadavers had rotator cuff tears. He also concluded that individuals with flat acromions were less likely to have rotator cuff tears than those with more curved (hooked) acromions.
Because of this recent research finding, Dr. Bigliani and his colleagues can better diagnose and recommend treatment for patients who have symptoms of rotator cuff disease. Through X-rays taken of the side of the body-a view developed at CPMC-physicians can better identify acromion morphology and determine the kind of acromion that causes rotator cuff problems so a portion of the acromion can be removed.
Dr. Bigliani also has improved surgical techniques involving the rotator cuff. He approaches surgery along a more posterior-facing region of the deltoid, the outer and uppermost muscle covering the upper arm. This access provides a better exposure of the rotator cuff and obviates the need for additional posterior surgery in massive tears.
He also has developed an "interval slide" method that frees one tendon of the rotator cuff so that the ripped tendons are more accessible to the surgeon for their ultimate point of attachment on the humerus.
The shoulder service is also credited with making advances in arthroscopic surgery. Arthroscopic methods are now used on an outpatient basis for conditions that in the past needed more invasive inpatient procedures. Arthroscopy of the shoulder allows a patient to use the arm within one week of the procedure vs. the four to six weeks that followed traditional surgery.
Dr. Bigliani hopes to continue to advance the understanding of the shoulder, keeping the shoulder service leading the world in shoulder care.