ROTATOR CUFF TEARS
What is the rotator cuff?
The shoulder is a ball and socket joint. It is a very loose and mobile joint and depends to a large extent on muscles to keep it stable. The rotator cuff is a group of four muscles that surround the ball of the shoulder joint. These muscles act together to provide stability to the shoulder joint. This allows the bigger muscles such as the deltoid muscle to elevate the arm. Without the rotator cuff, one would not be able to raise the arm above shoulder level.
Who gets rotator cuff tears?
Tears of the rotator cuff increase in frequency with age. They are very uncommon under the age of 40 years. They are more common in the dominant arm, and can be present in the opposite shoulder even if there is no pain. It is difficult to say how common cuff tears are because some people can have tears without any symptoms at all. The highest incidence is in people older than 60 years.
Why does the rotator cuff tear?
It is thought that there are two main causes:
- Degeneration of the rotator cuff tendons with age ie internal problems with the tendons
- Bone spurs rubbing on the tendons ie external forces acting on the tendons.
With increasing age, the blood supply to the rotator cuff decreases. It also decreases transiently with certain motions and activities. The substance of the tendon also degenerates over time. Because a good blood supply is important for rapid healing to occur, this decrease in the blood supply may impair healing and so contribute to tendon degeneration and complete tearing. The problem may be accelerated in people who perform repeated movements of the shoulder with the arm in certain positions such as above the head. This includes athletes such as baseball pitchers or cricketers, or people in professions such as window cleaning, painting and decorating etc.
A relatively common external factor that can cause damage to the rotator cuff is the presence of a bone spur on the shoulder blade. Such spurs tend to form with increasing age. The spur can rub on the tendon when the arm is raised above shoulder level. This is called “Impingement”. When this occurs repeatedly on a tendon compromised by poor blood supply and degeneration a tear can result.
Less commonly the rotator cuff can be torn by a sudden excessive force, for example a heavy fall which dislocates the shoulder.
What are the symptoms?
Rotator cuff tears can cause pain in the shoulder that can sometimes travel into the upper arm. The pain is often felt in the front or side of the shoulder. The pain is made worse on certain movements such as trying to raise the arm above shoulder level, reaching forwards or reaching into the back pocket. Pain at night is typical and may disturb sleep particularly when laying on the affected side. There may also be weakness of the affected shoulder and the patient may not be able to raise the arm above shoulder level. In larger tears there may be very little active shoulder movement possible (called “Pseudoparalysis”).
How is it diagnosed? Will any tests be required?
It can be diagnosed from the history and physical examination. Larger tears can be diagnosed relatively easily because of the associated weakness. Sometimes a local anaesthetic injection around the rotator cuff may be given to confirm that the pain is coming from the tear. In most cases a shoulder scan and x ray will be requested. The scan will show the size of the tear, the degree of muscle wasting and whether a repair is likely to succeed. It can also help predict the recurrence rate. The x ray will show any bone spurs and any underlying arthritis.
What happens if it is not treated?
This is difficult to predict. It is thought that tears involving the full thickness of the rotator cuff tendon do not heal on their own. There is some evidence that partial thickness tears may heal without surgical repair. A recent study showed that in about 40% of patients with a rotator cuff tear, the tear gets bigger with time. These patients generally become more symptomatic and in some the tear can get so big that they lose the ability to raise the arm.
How is it treated?
The best method of treatment is different for every patient. The decision on how to treat rotator cuff tears is based on how severe the symptoms are, the functional requirements and general health of the patient.
This typically involves activity modification (avoiding activities that cause pain), painkillers, anti-inflammatory medication, ice packs, physiotherapy and steroid (“cortisone”) injections. About 50% of patients have improved symptoms and are satisfied with the outcome of nonsurgical treatment.
However those with a long duration of symptoms (more than 6 to 12 months) or large rotator cuff tears tend to do poorly with nonsurgical management.
Surgical management is advised for those patients who do not respond to nonsurgical management particularly those with associated weakness, loss of function, and limited motion.
However those patients with tears caused by an acute injury or with very large tears when first seen may be offered early surgical repair without a trial of non-operative management as there is evidence that they do better with early repair.
What does surgery involve?
Surgery involves re-attaching the torn rotator cuff to the bone from which it has torn off and removing any bone spurs which may have contributed to the formation of the tear. The three commonly used surgical techniques for rotator cuff repair are:
- Open repair- this involves a large incision down the front or side of the shoulder and detachment of the large deltoid muscle covering the shoulder joint.
- Mini-open repair- this involves a medium sized incision (about 5 cm) on the side of the shoulder along with a few small “keyhole” incisions for arthroscopic removal of bone.
- Arthroscopic repair (the whole operation is done by keyhole surgery with no muscle detachment required)- this involves about 3 or 4 small “keyhole” incisions a centimeter or less in size.
The choice of technique depends on the individual surgeon’s familiarity and expertise with the technique. Arthroscopic repair is the latest technique. It is very demanding and requires rigorous training. Hence it is not offered by all shoulder surgeons. Initially, some rotator cuff tears were considered too large to be treated with this technique. However with experience, surgeons have found very large tears can be treated arthroscopically. I personally perform nearly all rotator cuff repairs arthroscopically.
The advantage of arthroscopic repair are:
- Better visualisation of the tear ( Tears are seen magnified in High Definition –like Sky HD!)
- Ability to treat other abnormailities found. The surgeon is not restricted by one incision as is the case with open surgery. He or she can insert the arthroscopic camera into all areas of the shoulder and repair problems which would be undetected or impossible to repair by open surgery.
- Lower complication rate than open surgery.
- No risk of deltoid muscle detachment or atrophy (which can occur in open repair)
- Early postoperative recovery is quicker
- Recent reports suggest that results are as good as or better than those achieved by open surgery -even for large or massive tears.
Prior to surgery, patients should discuss the options available to them with their surgeon.
How successful is surgery?
With proper patient selection, the success rate for relief of pain is about 90%. About 80% to 90% of patients achieve a satisfactory result with regards to restoration or improvement of function, improvement in range of motion, and patient satisfaction with the procedure. The success rate is lower in case of poor rotator cuff tissue quality (can often predict on MRI scan), large or massive tears, elderly patients, and in those patients who fail to comply with post-operative restrictions and physiotherapy.
What are the possible complications?
The complication rate for keyhole surgery in general is low. The main complications are:
- Nerve Injury (1% or less): The main risk is to the axillary and suprascapular nerves.
- Infection (1%): Use of antibiotics during the procedure and sterile surgical technique limits the risk of infection.
- Deltoid Detachment (less than 1%): Careful repair of the deltoid and protection during rehabilitation after an open repair procedure are important to avoid deltoid detachment. This complication should not occur after an arthroscopic repair because these procedures preserve the deltoid attachment or do not require detaching the deltoid.
- Stiffness (about 1%): Early physiotherapy and exercise protocols decrease the likelihood of permanent stiffness or loss of motion. Some degree of stiffness in the early postoperative period is to be expected however as the shoulder must be kept in a sling for a few weeks.
- Tendon Re-tear (about 6%): Several studies have shown that re-tears can occur following all types of repairs. The risk is higher in larger tears in poor quality tendon.
What is the recovery period after arthroscopic rotator cuff surgery?
After surgery, a special shoulder sling is used to rest the arm for six weeks. This is very important to protect the repair. Absorbable sutures are generally used and these do not require removal. Physiotherapy and a home exercise program are started at about 4 weeks. Most people in non-physical professions can return to work within a week or so but must wear the sling. Driving is to be avoided for at least 8 weeks. The torn rotator cuff may take many weeks to fully heal and recover its function, therefore some symptoms may persist for 3 months or more. Most patients have reasonable function and strength by 4-6 months.
- Wright JG .Evidence Based Orthopaedics . Saunders: 2009.
- American Academy of Orthopaedic Surgeons patient information.