INTRODUCTION
Rotator cuff tendon tears are a very common source of shoulder pain. The incidence of rotator cuff tendon tears increases with age. It is often related to a degenerative issue.
ANATOMY AND PHYSIOLOGY
The rotator cuff is formed by four main muscles which attach through their tendons around the superior aspect of the humerus head, thus surrounding the humeral head.
They are: the supraspinatus, infraspinatus, subscapularis, and teres minor. The long head of the biceps tendon is within the joint.
This group of muscles creates strength to lift and rotate the arm. It also contributes to shoulder stability. The supraspinatus tendon is more often involved in degenerative tear. Whilst most cases of rotator cuff tears are only degenerative, a previous trauma injury may precipitate.
SYMPTOMS
Rotator cuff tear incidence increases with age, repetitive movements or strength movements. Traumatic tears may occur after a forced movement or a fall. Sports injuries are a common cause of rotator cuff tear.
Symptoms of rotator cuff tears include:
Pain in moving the shoulder, and pain at night which may interrupt sleep.
Lack of strength which make it difficult to hold and lift things, or raise the arm
Biceps tendon tear is protruding so that the arm looks like “Popeye”.
The diagnosis of rotator cuff tear is based mainly on symptoms, patient's age, activities and history of previous injury.
The clinician will perform an examination to ascertain whether there is pain in specific maneuvers which could indicate rotator cuff injury.
IMAGING
Diagnostic imaging is a useful aid to diagnosis. X-ray, Ultrasound and MRI may be used.
If surgery is indicated, diagnostic images will identify the extent of damage, which tendons are affected and the degree of retraction of the tendon - which will inform the surgeon how and whether to proceed with surgery.
TREATMENT
The treatment will depend on several factors including the age of the patient, how disruptive the pain is how much the lack of movement and strength impact on the patients normal activities.
Two treatment options are considered:
Conservative treatment
Surgical treatment.
Conservative treatment
Conservative treatment will predominantly utilise physiotherapy with the aim of compensating the loss of strength of the deficient rotator cuff muscle by strengthening other muscles.
The symptomatic treatment of pain using anti-inflammatory medicine, or by one or two injections.
This type of treatment is favored if the pain is bearable, if surgery would not be recommended for the patient, or if the tear is non repairable.
Surgical treatment
- Surgical treatment of rotator cuff tears is preferable to conservative treatment, provided the degree of retraction is not too great for surgery to be successful. Over time an untreated tear will increase in size and could become non repairable.
-The surgical procedure consists of:
- reattaching the tendons on the humeral head with anchors
- removing the bony portion below the acromion, which contributed to pain (decompression).
This procedure can be performed under key hole surgery called arthroscopy.
Arthroscopic cuff repair should be performed by highly experienced shoulder surgeons.
If the rotator cuff tendons are too retracted to be fixed and a repair is impossible, a reverse shoulder replacement should be performed if the arm cannot be raised due to lack of strength.
COMPLICATIONS
The rotator cuff repair is a common procedure and postoperative complications are very rare. Complications include
Retear
Infection (< 1% of cases),
Stiffness - this is very unusual
POSTOPERATIVES CARE - PHYSIOTHERAPY
In order to promote tendon healing to the bone, a sling is used to completely immobilise the arm for three weeks. This sling should be worn day and night, maybe removed for showering.
After three weeks the sling is removed and the patient may begin to mobilize the arm with support from a physiotherapist who may recommend exercises such as those shown below.
When the pain has gone, and motion has recovered, the next stage is to introduce strength training exercises. Physiotherapy could last a few months.
SUMMARY:
Rotator cuff tendon tears are frequently seen in patients over the age of 50 demonstrated by pain on movement and also at night causing disturbed sleep for some patients. Early diagnosis is important so that the tear does not become no repairable.
Surgical treatment can restore the function and significantly remove pain. Surgery is simple, but should be performed by an expert shoulder surgeon.
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