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Rotator Cuff Tear

Rotator Cuff Tear web based movie

Rotator Cuff Tear

Rotator cuff is the group of tendons in the shoulder joint providing support and enabling wider range of motion. Major injury to these tendons may result in tear of these tendons and the condition is called as rotator cuff tear. It is one of the most common causes of shoulder pain in middle aged adults and older individuals. It may occur with repeated use of arm for over head activities, while playing sports or during motor accidents. Rotator cuff tear causes severe pain, weakness of the arm, and crackling sensation on moving shoulder in certain positions. There may be stiffness, swelling, loss of movements, and tenderness in the front of the shoulder.

Rotator cuff tear is best viewed on magnetic resonance imaging. Symptomatic relief may be obtained with conservative treatments - rest, shoulder sling, pain medications, steroidal injections and certain exercises. However surgery is required to fix the tendon back to the shoulder bone. Rotator cuff repair may be performed by open surgery or arthroscopic procedure. In arthroscopy procedure space for rotator cuff tendons will be increased and the cuff tear is repaired using suture anchors. These anchor sutures help in attaching the tendons to the shoulder bone. Following the surgery you may be advised to practice motion and strengthening exercises.

Calcific Tendonitis

Calcific tendonitis is a condition in which calcium deposits from within in the rotator cuff tendon, usually close to where it inserts on to the humerus. It is more common in middle-aged people. The exact cause of this condition is not known but it is thought that it may represent an abnormal response to injury in the setting of a degenerate tendon.

Xray (left) and MRI (right) demonstrating a large calcific deposit within the shoulder rotator cuff.

It causes pain, particularly during overhead function and also night pain, interfering with sleep.

Often before seeing an orthopaedic surgeon, patients will have tried a period of non-operative management which includes anti-inflammatories and activity modification, and perhaps a sub-acromial injection.

The best management for problematic calcific tendonitis is arthroscopic (key-hole) removal of the calcium deposit within the rotator cuff tendon. The deposit, which has a toothpaste-like consistency, can be effectively located with a needle under direct vision using the arthroscope. It is then removed from the tendon with a small curette, taking great care not to disturb surrounding cuff tendon.

Provided that there is no other structural problem with the rotator cuff tendon at the time of surgery the recovery is usually speedy. Shoulder rehab involves early physiotherapy and range of motion exercises.

Impingement

Shoulder impingement is the painful catching that occurs in the space between the head of the humerus and the shoulder blade arch (acromion). The pain occurs with elevation of the arm to shoulder height. The pain is felt down the outer aspect of the upper arm or into the biceps muscle region. The pain is often worse at night and interferes with sleeping.

Structures that occupy the subacromial space (blackened area) include:

  • The rotator cuff tendons. The rotator cuff muscle (supraspinatus) helps lift your arm up. The muscle sits on top of the shoulder blade and its tendon (yellow) runs through the subacromial space to connect to the head of the humerus
  • A fluid filled sac, called bursa (orange) lubricates the motion between the rotator cuff tendons and the acromion
  • The coraco-acromial ligament attaches onto the under-surface of the acromion

Causes of impingement include

  • Thickening of the contents of the subacromial space
  • The subacromial bursa in response to repetitive trauma can become thickened, inflamed and painful
  • The rotator cuff tendons with repetitive overload or aging can form degenerate thickened areas of scar (tendinosis). If the rotator cuff tears the retracted portion of the tendon thickens and the torn edge may catch on the boundaries of the tunnel. Rarely calcium deposits can form in the tendon (see calcific tendinitis).
  • The coraco-acromial ligament attachment may thicken or turn into a bony spur
  • Variations or changes in the bony margins can narrow the acromial space: different acromial shapes, bony spurring from the acromion or an arthritic AC joint and rarely an unstable piece of acromial bone (os-acromiale).
  • Dynamic factors: by avoiding the painful areas of above shoulder activity and reaching behind your back, secondary problems of rotator cuff weakness and stiffness occur that increase impingement.

Investigations of shoulder impingement include:

  • X-rays: can show acromial shape, acromial and AC joint spurs
  • Ultrasound: can show bursal thickening, rotator cuff degeneration or tearing and assess impingement with arm motion
  • MRI: is generally reserved for resistant cases of impingement where surgical treatment is being considered. It enables assessment of both bone and soft tissues

The treatment of shoulder impingement depends on the cause, duration of symptoms and disability and previous treatments.

The non-operative treatment involves:

  • Activity modification: activities that increase the pain and make sleep more difficult should be avoided in the acute inflamed stage and gradually reintroduced
  • Pain management: options include simple painkillers, anti-inflammatories and steroid injections into the subacromial bursa
  • Physiotherapy: can assist with restoring range of motion and rotator cuff strength. Progression to a swimming or gym-based exercise program completes the rehabilitation

Surgical treatment of impingement is reserved for patients with:

  • Greater than 6 months of pain and disability that is interfering with quality of life
  • Surgical targets (eg. acromial spurs) and evidence of impingement (thickened subacromial bursa) on MRI

The surgery involves increasing the size of the subacromial space for the rotator cuff tendons, by removing thickened bursa and abnormal bone. The surgery takes about 1 hour, requires an anaesthetic and can be performed as a day or overnight stay. A sling is worn for comfort only. Shoulder range of motion exercises are commenced the next day and a formal strength program begins around 4 weeks after surgery.

The surgery provides a relief of pain in 80-90% of patients. Operations specific risks include but are not limited to infection, skin nerve injury, shoulder stiffness and incomplete relief of pain.

Large Tears

Large Rotator Tears shall be defined as rotator cuff tears that involve more than 1 rotator cuff tendon. These tears may be acute or chronic or a combination of both (acute on chronic). If surgery has been suggested as a treatment option it is important to differentiate between acute, chronic or acute on chronic. An MRI scan (or CT arthrogram if claustrophobic) can be helpful with this differentiation.

Acute large tears may occur from a trauma such as a fall and may accompany shoulder dislocations in people over 50 years of age. If there have been no previous shoulder symptoms or injuries, then these large tears are more easily repaired. The retracted tendon will not have firmly scarred into its new position and is more easily pulled back to their bony attachment. The muscle bellies of the detached tendon will not have shrunk in size or been replaced by fat, as in prolonged tendon detachment (>6 months).
Chronic tears can occur over many years. A gradual loss of tendon attachment can be compensated by the remaining rotator cuff and deltoid muscles. More than half the population over 70 years of age has a full thickness tear in the rotator cuff tear and most have no symptoms. After a critical amount of tendon loss or a fall (acute on chronic) the tear may cause pain and loss of function. These tears are harder to repair. The retraction can be harder to overcome. If there is minimal residual muscle belly there may be little point in repairing the tendon. Ultimately the ability to repair some tears can only be determined at surgery after mobilising the tear. If a full repair is not possible a partial repair may help balance forces around the shoulder.

Most tears can be repaired with a keyhole technique although some may require a combination of keyhole and traditional open exposures. Other procedures addressing abnormal biceps tendon, acromial spurs and/or AC joint arthritis are commonly performed at the same time to assist with pain relief.

The main benefit of surgery is pain relief. Function is harder to improve, especially in chronic tears. Compared with single tendon repairs, large rotator cuff repairs are more likely to have incomplete healing or retear. The rehabilitation is therefore slower. Tendon healing is also harder to achieve in smokers and the very elderly.

Small Tears

The Rotator Cuff is a group of muscles and tendons around the shoulder. These muscles are important for the shoulder to function normally. They help balance the ball of the upper arm on the shoulder blade socket. A tear in one or more of these tendons can unbalance the shoulder and cause pain and weakness. It is common for these tendons to tear as people get older. Greater than 50% of people over 70 years of age have a full thickness tear at autopsy.The rotator cuff tears do not spontaneously heal. Despite the lack of healing there is greater than a 90% chance that a patient will have no pain and a return of most shoulder strength after 6-12 months.

  • Tendon firmly attached to bone
  • Full thickness tear of tendon from bone

The non-operative treatment of a painful rotator cuff tear includes activity modification, pain management and physiotherapy.

  • Activities should be modified to decrease the demands and stress on the effected shoulder during the painful phase
  • Pain management includes simple analgesics, anti-inflammatories and steroid injections
  • Physiotherapy helps restore shoulder range of motion and strength

Surgery is generally reserved for those who despite 6-12 months of non-operative therapy have ongoing pain and disability that is interfering with their quality of life. If a patient is considering surgery an MRI scan is organised to better define the abnormalities and ensure surgery is worthwhile.

Surgery involves restoring the anatomy, by attaching the torn tendon back to where it was originally attached. Traditionally, this was done via a large “open” incision. Recent technological advances have allowed “mini-open” and even all arthroscopic “keyhole ” rotator cuff repairs. These are technically demanding surgical techniques which aim to achieve equal results as traditional open surgery, while minimizing the surgical trauma to the patient. The surgery is performed with a camera on the end of a thin metal rod through 1cm incisions that penetrate but do not strip off muscles. This reduces the surgical insult, improves the cosmesis of the surgery and may lead to improved range of movement and less stiffness.

If surgery is performed to repair the rotator cuff, then in general a period of sling immobilisation is required for six weeks. You are not able to drive while in a sling. Physiotherapy may be required for 3 to 6 months assist recovery of motion and strength.

There are some situations when surgery should be considered as the best form of early treatment. These include but are not limited to:

  • A patient who has a massive rotator cuff tear and an inability to perform active shoulder movements following trauma.
  • A rotator cuff tear that has lead to an “unbalancing of the force couples” of the shoulder joint. This usually means that the tear is a massive tear and now the patient cannot lift their arm above shoulder level.
  • A full thickness rotator cuff tear in a “physiologically younger” patient. As this tear will never heal, some surgeons believe that the tear should be repaired in a younger patient. It is important to appreciate however that these patients may attain a pain free and functional shoulder with non-operative management.
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