Rotator Cuff Tear


The rotator cuff is formed of 4 muscles

  1. Supraspinatus
  2. Infraspinatus
  3. Subscapularis
  4. Teres Minor

They form a cuff over the top of the humerus.

They have two roles a) to rotate the humerus on the glenoid. b) To provide stability by compressing the humerus into the glenoid socket. They contract as a unit before any other muscle in the shoulder, anchoring the joint to allow the larger muscles around the joint, such as the deltoid, to create movement of the arm. In effect they are needed to counteract the forces developed by the large external muscles ( e.g deltoid and pectoralis major)

 

 

The most common site of a tear is within the supraspinatus muscle, but any or all of the muscles can be affected.

Tears cause a problem because the joint looses its stability and other problems arise as a result of this, such as impingement and lesions of the biceps. Ultimately, large, untreated tears can lead to severe,early secondary osteoarthrosis.

A tear is most common in people over the age of 40 due to degeneration of the tendon structure or lack of specific exercise , but can also occur in younger people as a result of an injury.

Common examples of when an injury is likely to occour :-
a) A fall onto an outstretched arm
b) Lifting a heavy object – especially from overhead to the ground
c) A sudden reach behind (eg reaching for something on the back seat of a car), especially when forced.
d) In association with a fracture or repetitive motions ie workers with overhead activities such as painting, plastering,construction or athletes such as swimmers, tennis players etc.

 

Signs and Symptoms

• Pain at the front or side of the shoulder which radiates down the side of the arm.
• Pain increases with overhead activities and during the movement of lowering the arm to the side.
• Night pain, especially when lying on the affected side.
• Weakness of the arm.
• Cracking or grinding.
• Wasting of the muscles around the joint.

Diagnoses

• Physical examination
• X- ray
• Arthrogram- this is when a local anaesthetic and dye is injected into the joint guided with x ray to detect the size and location of the tear.
• Ultrasound scan
• MRI

 


 

RC: Rotator cuff, B: biceps HH: humeral head

 

Arthroscopic view of a rotator cuff tear. A large space can be seen between the humeral head and the edge of the rotator cuff


Treatment Options

  • Rest and limit overhead activity.
  • Anti-inflammatory medication.
  • Steroid injection.
  • Physiotherapy to strengthen the muscles unaffected.

Managed conservatively, without surgery, it will take several months of exercise to regain the strength necessary to stabilise the joint.

Surgery – Rotator Cuff Repair – The type of surgery depends on the size, shape and location of the tear. A partial tear may require only a trimming or smoothing, a procedure known as debridement.

A larger tear in the substance of the tendon is repaired by suturing the two sides of the tendon. If the tendon is torn from its insertion onto the greater tuberosity of the humerus it can be repaired directly onto the bone.

ROTATOR CUFF REPAIR

 

Purpose

To relieve pain and improve rotator cuff function

 

Indications

Patients with pain or difficulty elevating the arm against gravity or lifting ,from repairable rotator cuff tears, either degenerate or tears resulting from an injury e.g sudden, heavy lifting.

 

Skin Incisions

Sagittal, superior/lateral aspect of the shoulder. This is designed to give the best cosmetic results.

 

Approach

The deltoid is divided between its fibers and detached from the front of the acromium to provide access to the torn rotator cuff. An acromioplasty is usually also required(link). This increases the sub acromial space and reduces the possibility of impingement and recurrent tear.

 

Procedure

The rotator cuff tear is located (most commonly in the supraspinatus tendon). The tendon is carefully released of all adhesions and bought back to its original position. It is then repaired, without tension directly to the bone utilizing small anchors secured within the bone. The bone surface has to be carefully prepared.

 

Possible Associated Procedures

Arthroscopy
Excision of the acromioclavicular joint
Sub Acromial Decompression
Manipulation Under Anaesthetic

 

Main Possible Complications

Infection
Impingement of the repair
Recurrence of the tear
Temporary or permanent nerve damage ( to the nerve supplying the rotator cuff muscles)
Detachment of the repaired deltoid muscle
Shoulder stiffness
Development of pain from pre-existing degenerative gleno-humeral joint arthritis. Severe arthritis can develop as a result of a bad, neglected rotator cuff tear.

 

After the operation

0-2 weeks

An abduction brace (either 15 or 30 degrees ) is applied in theatre.
Avoid all active movements
Seen by physiotherapist to be shown how to safely remove and re-apply brace and to perform passive, controlled shoulder movements.

2 Weeks Post Op

Wound and sutures are reviewed by the hospital or practice nurse.
Pain levels discussed to keep under control
Physiotherapist assesses active and passive range of motion
4 Weeks Post Op

Surgeon reviews deltoid and rotator cuff function, pain levels, active and passive range of motion and neurological function.
Physiotherapist progresses to active assisted exercises.

6 Weeks Post Op

Physiotherapy session to progress to full active exercise and discard brace.
12 Weeks Post Op

Surgeon assesses active and passive range of motion, anterior deltoid function and rotator cuff function.

6 Months Post Op

Final Review
Assess active and passive range of motion
Discharge with continuation of physiotherapy or review in a further 3 months
Continue home strengthening exercise programme and plan return to chosen sports/manual work/heavy lifting.