The shoulder is moved by the muscles and tendons of the rotator cuff. Between these and the acromium, which is part of the shoulder blade, we find the bursa, a kind of cushion. With repetitive shoulder activities, both the bursa and tendons can become injured and cause pain.
The impigment between the rotator cuff tendons and the acromion is a cause of pain in the shoulder and may be a result of an overbent acromion, calcium deposits in the shoulder tendons, wear in the joint of the most lateral part of the clavicle, complete rotator cuff ruptures, muscle imbalance between the different shoulder muscles or poor posture and poor mobilization of the shoulder blade.
Normally, surgery is only indicated when conservative therapies have failed. By conservative therapies we refer to analgesics and anti-inflammatories, physical therapy, posture corrections and self-exercises done by the patient at the patient’s home. Sometimes an injection of cortisone may resolve the problem and prevent surgery. Most impingment-induced shoulder pains improve with conservative therapies, with no surgery required. However, if pain persists despite these therapies, surgery may be indicated.
What is the role of the rotator cuff?
The rotator cuff keeps the humeral head centered on the joint and balances the joint in the movements of the shoulder. In addition they also actively participate in the mobilization of the shoulder.
Can rotator cuff tears spontaneously heal?
The circulation of a tendon that has ruptured is quite weak and the potential for spontaneous healing is very low. However, even without healing, the rupture may stop hurting. But even in a painless period the rupture can increase over time and reach a point where the tendon retracts and partially converts to fat and can reach a state where it is no longer possible to suture the tendon.
What causes rotator cuff tears?
In young patients they are usually caused by trauma and in the second half of life usually caused by wear and tear over the years.
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 a lancinating pain, in rotational movements, especially with the raised arm.
How is shoulder pain investigated?
The basis of the investigation are a physical examination and a shoulder radiograph. If an injury to the tendon is suspected, ultrasound or possibly a CT or magnetic resonance imaging may be used. It is sometimes necessary to inject a contrast agent into the joint during CT or resonance.
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, that is, without surgery, is possible in many cases. The basis of conservative treatment is physical therapy either with the help of a therapist in a physiotherapy center or at home with exercises that are taught to patients.
There are cuff injuries that remain stable over time and can be treated without surgery.
In recent (ie, acute) ruptures in young patients, surgery is almost inevitable. This surgery is usually done with arthroscopy.
If the rupture is not recent (ie, chronic) it may increase in size and the quality of the tendon may deteriorate to the point where it is no longer possible to suture the tendon. In these cases, joint cleansing may also be done by arthroscopy to remove structures that are causing pain such as tendon remnants or the bursa ("cushion" between tendons and bone).
In patients with advanced age the reverse shoulder prosthesis may be a solution in case of irreparable cuff tears.
What are the precautions to take after a suture of the hood?
In the first 6 weeks after surgery the patient will have to use 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.
Physiotherapy lasts approximately six months, 2-3 times per week in the first few weeks, and then gradually decreased to once a week, with regular follow-up by the GO 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 responsible is performed 6 weeks after surgery.
What 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 fat transformation) making it irreparable. The pace of this process is however difficult to predict. The force deficit and pain may persist or worsen. However, with physiotherapy, the neighboring tendons can compensate for some loss of function and with that the shoulder maintain the necessary strength to the patient’s daily activities.
Prolonged immobilization should be avoided due to the risk of stiffening the shoulder - a frozen shoulder.
What are the risks of operating a cuff tear?
The initial immobilization needed after surgery can lead to a stiff shoulder - a frozen shoulder. With age, the healing rate of the tendon after suturing decreases and there is a risk of further rupture. Full recovery of strength and range of motion may not be achieved in all cases. Returning to work, especially if it is physically demanding, can happen in some cases only at 6 months. The surgery requires regional or general anesthesia, which also has risks, although uncommon.
Conclusion on shoulder pain
Shoulder pain should not be treated lightly, although surgery is not necessary in most cases. If the pain is so intense that it has led to the need for cortisone injection, then a detailed investigation should be done.
Physical therapy plays a central role in the treatment of many shoulder diseases. If a rupture is confirmed whose symptoms do not improve with physiotherapy, arthroscopic surgery provides a minimally invasive solution to suture the tendon. However this decision requires the active participation of a highly motivated patient since the treatment, even after the surgery, takes several months.