Dr. E’s Terrible Rotator Cuff Tetrad!
Not All Rotator Cuff Injuries are Created Equal!
History of My Injury
For those who have not been following my Facebook posts; on the 9th of January I slipped on ice and severely injured my left shoulder. An X-ray of my shoulder taken on January 10th ruled out any fractures. However, all preliminary symptoms were pointing at the rotator cuff injury! At the time due to presumed elective nature of my rotator cuff management, delta COVID rampage in Michigan, and acute post-traumatic phases of my injury, I decided to postpone my MRI for two to three weeks. On January 31 after recession of my widespread left chest, shoulder, and arm ecchymosis (bruises), and dissipation of my acute pains, I underwent an MRI scanning at the radiology center of Michigan State University. MRI results were significant for total tears and retractions of three of my rotator cuff tendons, prominent labrum damages, and injuries and dislocation of the long head of my biceps brachii tendon. If you’re curious about the ‘labrum;’ it is the cartilaginous rim that functions as a bumper and surrounds the entire shoulder socket (glenoid)! Also, if you’re equally curious about the ‘ecchymosis;’ it is synonymous with bruise, contusion, and tissue hematoma, and it results from damages to tissue capillaries. Long story short, on February 24, I underwent an open surgery to fix the damages and hopefully, to allow me to optimally regain my major shoulder’s function.
During my original meeting with my orthopedic surgeon on February 11, he was convinced that based on my MRI and clinical findings, he should perform an open surgery on my shoulder. Despite this, and as part of his routine, he had to peek into my shoulder joint by an arthroscope for a quick, firsthand feel about the current status- and extent of the work that had to be done before beginning with my open surgery procedure! Later he told me that after peeking into my joint he knew that the extent of my injury was by far much worse than anticipated. As it turned out, the most important unforeseen negative contributing factor of my case was the extent of dislocation of my biceps brachii and partial tear of its long head. My bicep’s tendon’s tear and dislocation were marred by muscle recession, scarring, fatty infiltration, and edema of the involved tissues. As it has already been evidenced by my MRI, in addition to the bicep’s, I had total tears of three other rotator cuff tendon, and each tear was accompanied by its own compounding collateral damages such as adhesions, muscle recession, or other confounding issues.
What operation did my surgeon perform on my left shoulder on February 24?
Here is the summary of what my orthopedic surgeon performed on my shoulder: (1) biceps brachii tenodesis; (2) supraspinatus tendon repair; (3) infraspinatus tendon repair; and (4) subscapularis tendon repair. He had to drill a total of seven holes for properly attaching my four severed tendons into my left humeral head! Note that the end of my biceps tendon was inserted into the hole that was drilled on my humeral bicipital groove (see the rough position of the hole at the arrowpoint).
Not All Rotator Cuff Injuries are Created Equal!
On March 2, my orthopedic surgeon called me for a follow-up teleconference. Did I appreciate his call? You bet I did! During the meeting I asked from him: on the scale of 0 to 100 with ‘zero’ being ‘just a piece of cake’, and ‘100’ being ‘too complicated or too messed up’, how would do you rate the extent of my injury, the difficulty level of my operation, and my prognosis? His answer was… 95%!
Dr. E’s Terrible Rotator Cuff Tetrad!
The magnitude of my left shoulder injury forced me to think about a more user-friendly term for communicating my story with my colleagues and students. As a result, I coined this descriptive term for my combined injuries: My Terrible Rotator Cuff Tetrad! Then, it occurred to me that I should search the literature to see if anyone has already used the ‘terrible tetrad’ in the context of rotator cuff injury. The result was astounding! I was the first person who has produced a descriptive term for this type of severe rotator cuff injury! Well, as a result it doesn’t matter if we refer to it as ‘Dr. E’s Terrible Rotator Cuff Tetrad’ or, simply as Terrible Rotator Cuff Tetrad hereafter! What does Terrible Rotator Cuff Tetrad entail? It entails total tear of four rotator cuff associated tendons, namely, the long proximal biceps brachii; supraspinatus; infraspinatus; and subscapularis! Please note that my biceps tendon was partially torn as a result of my accident; however, the surgical procedure of tenodesis implies elective excision of the entire proximal end of the long head of the biceps tendon that normally originates from the supraglenoid tubercle of the scapula. Also note that the supraglenoid tubercle is immediately located on top of the glenoid fossa or cavity. For this reason, quite often traumatic tears of the labrum, that is, the upper parts of glenoid fossa will also traumatize the long head of the biceps tendon!
Now that I defined and described the terrible rotator cuff tetrad, can you guess what I mean when I say “terrible rotator cuff pentad? The pentad in addition to all cited tears of the tetrad, also includes the tear of teres minor. As the name of ‘teres minor’ implies, this muscle has a more limited role in shoulder movements!
What lies ahead? Well, as you can tell given the extent of my rotator cuff injury, my work is cut out for me, and I see much rehab and physiotherapy in my near future! However, what matters most to me at this point is “how am I going to adjust to my new musculoskeletal limitations, and to what extent my shoulder injury blends into the conquest of my own holistic longevity”! If you ask me what I wish to do with my shoulders again… I’ll tell you… just peek at the following swimmer’s picture! It says it all!
Epilogue
It just occurred to me that some of my inquisitive followers and students may like to know more about the surgical process of biceps tenodesis. For practical purposes, tenodesis is only used in conjunction with the bicep’s injuries! I have selected two awesome animated videos for you. The total time to watch both is less than 3.5 minutes. The first video is produced by the Ortho Illustrated Animation, and the second one by Professor Duncan Tennent. Please enjoy!
www.youtube.com/watch?v=WnlmaE5z9h0&ab_channel=Arthrex
www.youtube.com/watch?v=_m5cFfMEUm4&ab_channel=PromedonS.A.
Dr. E
Dr. Eftekar (Dr. E) is the founder and head coach of the Center for Conquest of Longevity and Northwestern Medical Review. A unique attribute of Dr. E is his well-rounded academic background that, in addition to the science of medicine, extends over several other disciplines such as physiology of aging and longevity, philosophy of science and medicine, and integrated kinesiology.