Rotator cuff disorders (tendinopathy, tears)
What are the Rotator cuff tears?
A rotator cuff is a group of four muscles that are critical in the movement and stability of the shoulder joint. It comprises of supraspinatus, infraspinatus, teres minor and subscapularis, which connect the head of the humerus to the shoulder blade. Its main function is to attach the arm bone firmly with the shoulder blade. It essential for lifting and rotating the arm and keeps the arm firmly in the socket of the shoulder.
Rotator cuff disease is the most common cause of shoulder pain in adults, could be injured due to trauma, falling on outstretched hands, accidents, heavy weight lifting, or repeated overuse in sports such as tennis, baseball, or professions such as carpentry, painting, etc. It could also be affected due to degeneration in older patients, inflammation and mechanical damage from acromial spur. Rotator cuff tears are more prevalent in people above 60 years of age due to degenerative wear and tear. Studies have shown that 50% of the population above 80 years have cuff tear. Most of the times, it is associated with other shoulder conditions such as impingement syndrome, AC (Acromio-clavicular joint) ailments, and in advanced cases with arthritis and shoulder dislocation or subluxation.
What are the symptoms of Rotator cuff disease?
Its symptoms include pain and tenderness in the affected shoulder, especially with overhead activities. The pain usually is localised to outer upper arm and radiates down towards the wrist. Pain is dull aching type when you attempt to lift something or to lower down your arm. Pain is felt at night or at rest in sleep, mostly when you lie on the affected shoulder.
When the tendon is completely torn, the shoulder becomes weak with loss of normal ROM (range of motion). Passively the shoulder joint could be moved. Clicking or crackling sound is also common with certain shoulder movements.
How is it diagnosed?
After the evaluation of your complete medical history, your symptoms, and physical examination, your surgeon can diagnose rotator cuff tears. X-ray is helpful to find out any other abnormality in the shoulder joint and glenoid space (space in the shoulder joint). MRI scan or Ultra sound scan is essential to know the extent of damage to the soft tissues and also to assess the quality of the rotator cuff.
What happens if nothing is done?
The tendinopathy or partial tear of rotator cuff could get better with rest, however it could lead to frozen shoulder or joint stiffness and weakness of the cuff muscles. In patients with cuff tear, if it is neglected or left untreated, the size of the tear could progress and lead to permanent weakness and loss of motion of the affected arm. In later stages it could lead to arthritis (cuff tear arthropathy) of the shoulder joint.
How is it treated?
It can be treated either conservatively or surgically. Conservative methods involve rest, heat or cold application, medications, steroid injections and physiotherapy.
Surgery is indicated in-
- Recalcitrant rotator cuff tendinopathy
- Patients with severe rotator cuff disease not responding to conservative treatment
- Traumatic rotator cuff tear
- Full thickness tears
- High grade partial rotator cuff tears
- Massive cuff tears
What are the non-operative treatments?
Most patients with rotator cuff tendinopathy and partial cuff tears benefit from non-operative treatment. The non-operative treatment of comprises of following-
- Rest– the patient is encouraged to take proper rest and restrict overhead activities. The surgeon instructs the patient to avoid those activities that can cause pain in the shoulder. A shoulder sling may be applied to ensure proper healing and avoid any new injury to the shoulder.
- Heat or ice application– hot or cold packs can be used two to three times in a day for 20-30 minutes to relieve swelling.
- Medications– painkillers like paracetamol or codeine are given to control pain. Anti-inflammatory drugs such as aspirin or ibuprofen are prescribed to manage pain and swelling.
- Physical therapy- it is centered on the exercises that can strengthen the muscles of the shoulder. The whole set of exercises, designed by your physiotherapist will stretch your muscles to regain normal range of motion and flexibility of the shoulder. It is started with gentle exercise like pendulum exercises of the shoulder, slowly progressed to strenuous strengthening exercises of the shoulder. During immobilization, elbow, wrist and hands are kept mobile to prevent stiffness and maintain their normal function.
Steroid injections- when all the above measures fail, then your surgeon may inject cortisone (steroid) directly into your shoulder to manage inflammation.
What does the operation involve?
The surgery is performed in patients with failed conservative treatment and those with completely torn rotator cuff. The main goal of the surgery is to remove inflammatory tissues, create more space for rotator cuff tendons (shaving of a small part of acromion) and repair the muscles to restore normal strength and range of motion. The surgery can be done by arthroscopy, open repair or mini-open repair.
- The author usually performs the surgery using keyhole surgery (arthroscope) as a day case under regional/general , 2-4 small 1cm cuts are made and a tiny camera (arthroscope) is inserted through the cut to locate and assess the rotator cuff.
- The muscles are repaired by reattaching the rotator cuff tendons to the arm bone with suture anchors. Bony spurs or projections if present are removed out of the shoulder joint.
- The surgical time is usually 1-3hrs and majority of the patients go home the same day usually after 10 hours of operation. The associated pathologies if found are addressed at the same time.
What happens after surgery?
- The effect of local anaesthesia ends in 4- 10 hours after surgery. The patients are encouraged to take painkillers before they can experience pain usually for 48 hours. In this way, many patients do not report pain.
- The patient is discharged on the same day and advised to take rest and modify his activities based on the procedure. A sling is applied for 2 to 6 weeks to support healing by immobilization.
- Before discharge, the patient is taught set of gentle exercises of the shoulder. These exercises can be started from the day one after the surgery. These exercises are important to reduce stiffness and pain and restore strength and normal range of motion of the shoulder and arm.
- Light activities like using a keyboard or writing are allowed if they don’t cause excessive pain or discomfort.
- The patient is reviewed again after 2 weeks for the check of wound and physiotherapy.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
- Physical therapy is advised to ensure rehabilitation. Following cuff repair, between 2 and 4 weeks, patients are allowed to do gentle exercices. Full range of movement exercices around 6 weeks and more strenuous exercises are advised around 3 months. Your physiotherapists and surgeon will guide you for the choice and duration of the exercises. These exercises can improve your shoulder posture. The exercises are designed in such a way that you can regain the range of motion of the shoulder with the strength of the arm.
Are there any risks?
- Damage to the nerves, vessels or tendons
- Repair failure
- Irreparable tear
- Recurrent rotator cuff tear
- Persistent shoulder pain, weakness and stiffness
- Injury to the suprascapular nerve
- Axillary nerve injury
- Frozen shoulder
What are the results of the operation?
The success rate of surgery in rotator cuff tears is > 90% with fast recovery and minimal complications. However, the results depend on the age of the patient, his profession, duration, the extent of damage of the muscles and surgery performed. The outcome is more predictable in the author’s experience.
When can I return to driving and work?
Depending on your job, you can return to work in 2 weeks (desk job) to few months (manual labour) and start driving after 6 -10 weeks. Depending on the size and duration of the tear the recovery starts in 6 weeks to 3 months after surgery. However, for a full recovery it may take a year or two to regain full functioning of the shoulder. Your surgeon can give you correct advice for this.
- Intact supraspinatus muscle: arrow shows the tendinous attachment to the bone
- Completely torn and retracted supraspinatus muscle: arrow demonstrates the tear and the gap filled with inflammatory fluid.