Rotator Cuff Tear(s)

What is the Rotator Cuff?

The shoulder is one of the most complex joint of the body formed by the articulation of three bones – the Humerus, the Clavicle and the Scapula. The shoulder joint is a complex of four joints. The glenohumeral joint, which is the main ball and socket joint, the AC joint, the sub acromial joint (space) and the scapula thoracic joint (space). Pain and clinical problems can arise from either of these joints.

The rotator cuff is a group of four muscles supraspinatus, infraspinatus, subscapularis, and teres minor, often referred to as ‘SITS’. These are attached to the scapula (shoulder blade) on the back through a single tendon unit. The unit is attached on the side and front of the shoulder on the greater tuberosity of the humerus. There is a bursa (sac) between the rotator cuff and acromion that allows the muscles to glide freely when moving.

Rotator Cuff Tear (RCT) is a common cause of pain and disability among adults. Most tears occur in the supraspinatus muscle, but other parts of the cuff may be involved. When rotator cuff tendons are injured or damaged, this bursa often becomes inflamed and painful. One or more tendons can be torn at the same time.

Causes of Rotator Cuff Tears

The rotator cuff tear can be ‘acute’, ‘chronic’ or a combination of both.

Degenerative Tears
Common presentation where patients have had shoulder pain for months to often years. This is as a result of overuse of muscles and tendons over a period of years. People who engage in repetitive overhead motions are especially at risk of RCT andinclude those playing sports such as baseball, tennis, weight lifting, and rowing. This is common in people who are over the age of 40. Rotator Cuff Tears increase in frequency with age, are more common in the dominant arm, and can be present in the opposite shoulder even if there is no pain (asymptomatic)

Traumatic Tear
A significant episode of trauma can cause tear of the rotator cuff. This is usually seen in younger people and is associated with significant pain and loss of use of the arm. This may be associated with a shoulder dislocation. In the older age group patients (over 65 years) this may be a massive tear which is often irreparable.

Symptoms & Signs of Rotator Cuff Tears

Pain when lifting or lowering the arm
Difficulty with activities of daily living especially overhead work
Pain at night & difficulty in sleeping on side
Muscle wasting around shoulder
Weakness when lifting/rotating the arm
Crepitus or crackling sensation when moving the shoulder

Diagnosis

Diagnosis of a rotator cuff tear is based on the symptoms and physical examination. X-rays, and MRI (magnetic resonance imaging) or ultrasound, are also helpful. An MRI (pictures) can tell how large the tear is, as well as its location within the tendon itself or where the tendon attaches to bone. It also tells the surgeon the extent of retraction and the quality of the tendon. An ultrasound may be utilized but is operator dependent and hence I do not recommend it routinely.

Treatment

This depends on patient factors and tear size and morphology. Most of the tears do get bigger with time, and are also associated with worsening of symptoms. The incidence of ‘asymptomatic’ rotator cuff tear increases after the age of 60 years.

Nonsurgical Options

Non-steroidal/Anti-inflammatory medication
Sling and limited overhead activity
Steroid injection (in some cases)
Strengthening exercises and physiotherapy

Surgical Treatment Recommended if:

Non-surgical treatment does not relieve symptoms
The tear is painful
Traumatic Tears – acutely

Types of Surgical Treatment

Arthroscopic Repair

A fibre-optic scope and small, pencil-sized instruments are inserted through small andis connected to a television monitor and the surgeon can perform the repair under video control. This technique uses multiple small incisions (portals) and arthroscopic technology to visualize and repair the rotator cuff. I usually carried out this as a day case procedure.

Mini-Open Repair

The incision is typically 3 – 5 cm in length. I usually use this technique in presence of an acute injury that is accompanied with a bone fragment coming off with the rotator cuff.

Open Surgical Repair

This is a traditional open surgical incision is sometime required especially if additional reconstruction, such as tendon transfer is needed. It may be employed, if additional procedures are carried out.

If you have shoulder pain and think it could be a Rotator Cuff Tear, please contact my secretary to book an appointment.