Rotator cuff tear
What is the rotator cuff?
Rotator cuff is the name given to the set of four muscles that originate in the shoulder blade and join in a tendinous structure that is inserted into the head of the humerus. This structure involves the glenohumeral joint of the shoulder, as if it were a sleeve, keeping the head of the humerus centered on the joint and balancing the joint during shoulder movement. It is also actively involved in this mobilization.
What causes it to tear?
Rotator cuff tears in young patients are usually triggered by trauma and in the second half of life usually caused by wear and tear over the years. The cuff tear usually consists of the disinsertion of the tendon of the bone in the humerus. This causes the muscles to not function properly and causes pain.
Can the tear heal spontaneously?
The blood circulation of a tendon that has ruptured is quite weak and the potential for spontaneous healing is very low. However, even without healing, the tear may stop hurting. Although in the absence of pain, the tear can increase over time leading to the retraction of the tendon that partially converts to fat, making it impossible to repair it in the future.
What are the symptoms of a rotator cuff tear?
The typical symptoms of a rotator cuff injury are shoulder pain (more intense at night), loss of strength and agility in the shoulder, and often an acute pain in rotational movements, especially with overhead movement.
How is the diagnosis made?
The basis of the investigation are the physical examination and a shoulder radiograph. If an injury to the tendon is suspected, an ultrasound may be used to make the diagnosis. For better therapeutic guidance, magnetic resonance imaging is helpful, and there may be room for computed tomography (CT). In specific situations, it may be necessary to inject a contrast agent into the joint during the last two exams.
How are rotator cuff lesions treated?
Treatment depends, among other factors, on the patient's age, sports activity, extent of injury and condition of the tendon. Conservative treatment, without surgery, is possible in many cases. The basis of conservative treatment is physiotherapy either with the help of a therapist in a physiotherapy center or at home with exercises that are taught to patients.
There are cuff lesions that remain stable over time and can be treated without surgery.
In recent (ie, acute) tears in young patients, surgery is almost inevitable. This surgery is usually done by arthroscopy, in order to repair the rotator cuff. Although open surgery yields good results, in most cases arthroscopic repair is preferred. Arthroscopy allows a more detailed intraoperative assessment of anatomical structures and allows reconstruction to be performed by sparing the muscles around the joint. The purpose of the operation is to attach the torn tendon back to the bone, in its original position. The tendons are fixed to the bone in a stable way through bone anchors, which may be plastic, metal, absorbable material or made up of suture threads. Simultaneously acromioplasty is frequently performed (remove a few millimeters of bone from the underside of the acromion). The goals of surgery are to improve the pain and restore the strength of the shoulder muscles.
In non-recent (i.e., chronic) tears, the cuff tear may increase in size and the quality of the tendon may deteriorate to the extent that it is no longer possible to suture it. In these cases, joint cleansing can be done, also by arthroscopy, to remove structures that are causing pain such as tendon debris or bursa (the "cushion" between the tendons and the bone). The débridement of the cuff by arthroscopy is performed either on very small tears that are not relevant or on very extensive tears that can no longer be sutured. The unstable portions of the tendons and inflammatory tissue are removed. The purpose of this operation is to achieve a decrease in pain. After this operation, no immobilization is necessary and rehabilitation is simple.
In rare cases, when the tendon is very thin it may be necessary to place a tissue-like structure on the tendons as a kind of biological reinforcement of the suture. In large ruptures where the tendons are in such poor state that does not allow suturing, it may be necessary to apply special surgical techniques such as tendon transfers. In these cases damaged tendons are replaced by redirected tendons of the chest or back. Tendon transfers are, however, last resort solutions, with limited results and it is usually not possible to recover a totally normal function.
In patients with advanced age the inverted shoulder prosthesis may be a solution in case of irreparable cuff tears.
How’s the post-operative care after a rotator cuff repair?
In the first 6 weeks after surgery, the patient will have to keep the arm to the chest with a special cushion to keep the elbow raised so as to decrease the tension forces in the sutured tendon.
Physical therapy lasts for approximately six months, with a frequency of 2 to 3 times a week in the first few weeks, and then gradually decreased to once a week, with regular follow-up by the physiotherapy team. The inability to work depends on the type of work and can vary between 3 to 6 months.
The follow-up consultation with the surgeon in charge is performed 6 weeks after surgery.
Which are the risks of not operating a cuff tear?
Tendon rupture may increase over time and the tendon may retract and undergo degeneration (with partial transformation into fat) making it irreparable. The pace of this process is difficult to predict. The force deficit may persist or worsen, as well as the pain. However, with physiotherapy the neighboring tendons can compensate for some loss of function so that the shoulder could maintain the necessary strength for the patient’s activities.
Prolonged immobilization should be avoided by the risk of stiffening the shoulder - a frozen shoulder.
Which are the risks of operating a cuff tear?
The initial immobilization required after surgery may lead to frozen shoulder - shoulder stiffness. With age, the healing rate of the tendon after suturing decreases and there is a risk of further rupture. Complete recovery of strength and range of motion may not be achieved with surgery in all cases. Returning to a physically demanding work, can happen in some cases only at 6 months. The surgery requires regional or general anesthesia, which also has risks, but are uncommon.
After completion of postoperative rehabilitation, it is often possible to achieve a significant reduction of pain and restore shoulder function. Occasionally a slight force deficit may remain even after rupture suture.