Rotator Cuff Tear

Anatomy of rotator cuff

The shoulder is a ball-socket joint that allows the arm to move in many directions. It is made up of the humeral head (the upper end of the bone of the upper arm) fitting into the glenoid fossa of the scapula (shoulder blade). The humeral head is kept in place by the joint capsule and labrum, thick bands of cartilage that form an elongated cone where the humeral head fits. The rotator cuff muscles are the dynamic stabilizers and movers of the shoulder joint and adjust the position of the humeral head and scapula during shoulder movement.

In most parts of the body, the bones are surrounded by muscles. In the shoulder region, however, the muscle is surrounded by bone. If one taps on the top of the shoulder, bone can be felt immediately under the skin. Underneath that bone is the muscle that lifts the arm. The rotator cuff muscles of the shoulder are sandwiched between the arm bone and the top of the shoulder (acromion). This unique arrangement of muscle between bone leads to the condition of impingement syndrome (shoulder bursitis, rotator cuff tendinitis).

The term "Rotator Cuff" is used to describe the group of muscles and their tendons in the shoulder that helps control shoulder joint motion. The supraspinatus is at the top (superior) of the shoulder, the Subscapularis is anterior (front), and the infraspinatus and Teres minor are posterior (behind). These muscles insert or attach to the humeral head by way of their tendons. The tendons fuse together giving rise to the term "cuff." Although each muscle acting alone may produce an isolated rotational movement of the shoulder, the role they play together is to help keep the humeral head (ball) centered within the glenoid (socket) as the powerful deltoid and other larger shoulder muscles act to lift the arm overhead.

Causes of rotator cuff tear

The muscles and tendons in the rotator cuff group may be damaged in a variety of ways. Damage can occur from an acute injury (for example from a fall or accident), from chronic overuse (like throwing a ball or lifting), or from gradual degeneration of the muscle and tendon that can occur with aging.Rotator cuff pathology can be caused by extrinsic (outside) or intrinsic (from within) causes. Extrinsic examples include a traumatic tear in the tendon(s) from a fall on out stretched hand or accidents . Overuse injuries from repetitive lifting, pushing, pulling, or throwing are also extrinsic in nature which tear tendons even with trivial or no injury. Intrinsic factors include poor blood supply, normal attrition or degeneration with aging, and calcific invasion of the tendon(s). Usually in young individuals significant extrinsic trauma and in older individuals more of intrinsic factors making cuff tendons so weak that even trivial or no trauma leads to cuff tears. That is the reason that in older individual sometimes cuff tears are asymptomatic.

Rotator cuff "tendonitis" is the term used to describe irritation of the tendon(s) either from excessive pressure on the acromion or less commonly from intrinsic tendon pathology. Irritation of the adjacent bursa is known as Subacromial "bursitis." Repetitive overhead activities resulting in irritation of the tendon(s) and bursa from repeated contact with the under surface of the acromion is called "Impingement Syndrome."

Rotator cuff dysfunction is typically a continuum of pathology ranging from tendonitis and bursitis to partial tearing, to a complete tear in one or more of the tendons. Although the earlier stages may resolve with conservative care, actual tearing of the tendon can be more problematic. These tears most commonly occur at the tendoperiosteal (tendon to bone) junction. Because this area has a relatively poor blood supply, injury to the tendon here is very unlikely to actually heal. Additionally, the constant resting tension in the muscle-tendon unit, or "muscle tone", pulls any detached fibres away from the bone, preventing their reattachment. Finally, joint fluid from within the shoulder may seep into the tear gap preventing the normal healing processes from occurring. This process continues to repeat itself with activities of daily leaving causing recurrent symptoms of the impingement. These symptoms typically disappears when person avoids provocative overhead activities only to reappear again with resumption of activities. This the reason that even with complete rotator cuff tear individuals can still have painless intervals off and on.

Symptoms of Rotator cuff tear

Patients with rotator cuff pathology commonly present with an activity related dull ache in their upper lateral (outer) arm and shoulder. Above shoulder level activity is usually most difficult. Many people have little to no discomfort with below shoulder level activities such as golf, bowling, gardening, writing or typing, etc. Conversely, tennis, baseball/softball, basketball, swimming, painting, etc. will be more problematic.Pain in the shoulder may extend down as far as the elbow, but not usually beyond. Neck pain on the same side may develop later as a result of using the scapular elevators excessively to compensate for abnormal glenohumeral motion. These scapular elevators, such as the trapezius originate from the cervical spine and can cause pain in the posterior neck and well as occipital (low) headaches. Patients may also experience snapping or cracking within the shoulder, pain at night, difficulty lying on the involved shoulder, and difficulty getting dressed. Late findings include weakness and loss of shoulder motion.These symptoms are also similar to shoulder impingement like difficulty reaching up behind the back, pain when the arms are extended above the head and weakness of shoulder muscles.If shoulder muscles are injured for a long period of time muscles are actually tear in two parts what is known as full thickness tears,it causes very significant weakness and, on occasion, inability to elevate the arm against gravity. Some patients will have rupture of their biceps muscle as part of this continuing impingement process. The pain is more or less continuous and also significant night pain leading to disturbances in the sleep.

The Diagnosis of rotator cuff tear

X-rays will not show the rotator cuff, but they will reveal any evidence of arthritis, spurs within the shoulder, loose bodies, fractures from a related fall, abnormal displacement of the humerus out of the glenoid, and congenital (birth) related problems. Therefore, good quality x-rays are a must in the proper evaluation of the shoulder.

Ultrasound examination is good tool to rule out actual significant rotator cuff tear as a screening process but it is dependent on the quality and specificity of machine and experience of the radiologist. The MRI scan is mandatory for the operative treatment plan of the rotator cuff tear.

Magnetic Resonance Imaging or MRI has allowed visualization of the soft tissues of the body, including the rotator cuff. An MRI can depict tendonitis, partial tearing, and complete tears of the rotator cuff. While an MRI is usually not required to diagnose a torn rotator cuff, it can be very helpful to determine which tendons are torn, how large the tear is, the degree of tendon retraction, the extent of muscle belly atrophy (shrinkage), and any coexisting problems.

Conservative treatment

Many rotator cuff tears do not require surgery. Conservative treatment of rotator cuff disease classically includes rest, activity modification, nonsteroidal anti-inflammatory medications, and physical therapy. Therapy may include heat, cold, ultrasound, electrical stimulation and other modalities, but the hallmark of an effective rotator cuff rehabilitation program is therapeutic exercise. Stretching of particularly the posterior joint capsule can help the tendency of the humeral head to migrate superiorly toward the acromion with forward elevation. Strengthening of the remaining rotator cuff through resistance exercises can again help contain the humeral head within the glenoid and avoid undue pressure up on the acromion. Finally, muscle re-education to normalize the mechanics of shoulder motion can help return the patient to his or her full function.

Operative treatment

Patients with more advanced rotator cuff disease or a more significant injury may fail efforts at conservative therapy. If the patient feels that his or her quality of life is being significantly impacted by the shoulder dysfunction, then consideration of surgical intervention is certainly reasonable. In some cases simple debridement of a frayed or partially torn cuff tendon along with smoothing of the undersurface of the acromion (acromioplasty) above the tendon may be all that is needed. More significant partial tearing (more than 50% of the tendon thickness) and complete tears require reattachment of the tendon ends back to the humeral head.

Rotator cuff repair was done by an open surgical procedure in old times, which typically requires a 2 to 4 inch incision at the top of the shoulder. The deltoid muscle is split and the undersurface of the acromion is smoothed. Strong stitches are placed in the torn ends of the rotator cuff tendons, and they are attached back the bone of the humerus through specially created tunnels or commercially available suture anchors. Because the entire shoulder cannot be visualized through the open approach, long healing period needed and limited outcome of the procedure, many surgeons these days feel that arthroscopic surgery is best available treatment in current scenario.

Arthroscopic techniques for rotator cuff repair were developed over 20 years ago and have been continually refined. This is an extremely difficult approach for the surgeon to initially learn, but once mastered, can be quite rewarding for both doctor and patient. I have been using arthroscopic technique successfully in all my patients since last 10 years with gratifying results.

Unlike the open technique, the portals used for an arthroscopic repair are very tiny. There may be 3 to 4 of such very small 5mm portals, the patients have much less postoperative pain and require less prescription pain medication, postoperative recovery is faster and superior. This is usually done as an day- care procedure at my clinic.

Arthrotunneler Anchorless Cuff repair

Post-Operative rehabilitation

rotator cuff repair is a major operation that requires considerable rehabilitation. Several rehabilitation protocols for rotator cuff repair are available and are based on the size of the tear and repair. The shoulder is typically protected in a sling for 4 to 10 weeks, although some gentle passive motion is typically begun almost immediately.

It takes 12 weeks for the tendon to begin to heal down to the bone, and that the attachment continues to mature and strengthen for 2 years. Despite the prolonged healing course, patients can very often begin light computer work or writing in 6 weeks, lift the arm overhead 2 to 4 months after surgery depending upon type and health of cuff tissue. Participate in household work table work & other less strenuous activities at 4 months, and return to full sports and work participation at 6 to 8 months.

Long term studies have revealed 80 to 95 percent good to excellent results for rotator cuff repair done r arthroscopically. Patient satisfaction rates are high. In the majority of these studies, over 90% of patients agreed that in retrospect they would have the surgery again if needed. A well-motivated patient combined with a well-done repair and a comprehensive rehabilitation program, typically results in a satisfied patient who is able to return to his or her normal activities of daily living with little to no compromise.