ROTATOR CUFF TEAR

Overview

The shoulder joint is surrounded by a group of muscles and tendons called a rotator cuff.  It keeps the head of the arm bone stable in the shallow socket of the shoulder blade. The rotator cuff is made of 4muscles viz. supraspinatus, infraspinatus, subscapularis and teres minor.  It is a supraspinatus tendon that is torn most of the time.

Causes

Rotator cuff disease is usually the result of either a substantial injury to the shoulder or to progressive degeneration or wear and tear of the tendon tissue. Repetitive overhead activity or heavy lifting over a prolonged period of time may irritate or damage the tendon. Rotator cuff injuries are common in old age especially in those who retired from jobs that required repeatedly performing overhead motions like painters and carpenters. In the elderly, it is usually degenerative. Most will either have no history of trauma or trivial injury (carrying weight or taking support of arm while balancing). Young people can also get rotator cuff tears but most of them are traumatic.

Diagnosis

Pain is the most common symptom associated with a rotator cuff injury. Pain is usually a dull ache deep in the shoulder. It is positional and disturbs sleep. Motion is not lost initially however pain makes it difficult to move. Pain makes it difficult to comb your hair or reach behind your back. Pain may be accompanied by arm weakness and loss of active motion. Many tests are performed to clinically diagnose rotator cuff disease.

Your doctor may recommend imaging tests, such as X-rays, Ultrasound and Magnetic resonance imaging (MRI) to diagnose the disease accurately and associated other problems. X-rays are the basic tests to know about bone, arthritis and spur. USG is a low-cost investigation that can diagnose rotator cuff tears accurately. MRI is the most commonly used modality to diagnose and plan the treatment of rotator cuff injuries.

Identification of rotator cuff tear is important as without treatment, rotator cuff problems may lead to permanent loss of motion or weakness, and may result in progressive degeneration of the shoulder joint.

Treatment

Most rotator cuff diseases can be treated conservatively. Conservative management includes the following:

  1. Rest
  2. Ice fomentation
  3. Physical therapy: after the pain and inflammation have subsided exercises are started to achieve flexibility, muscle balance, and strength. 
  4. Injections: If the above treatments haven’t reduced your pain, your doctor might recommend a steroid injection into your shoulder joint. While these injections are temporarily helpful, they should be used cautiously, as they can contribute to the weakening of the tendon and may lower the success of surgery if this is eventually needed.
  5. Medicines: pain killers such as NSAIDs (ibuprofen, diclofenac) can be used to get relief from pain.

 

Surgery

Many different types of surgeries are available for rotator cuff injuries, including:

  1. Arthroscopic tendon repair: It is a minimally invasive procedure in which the joint is reached and the tear is repaired with the use of a small telescope (arthroscope) and surgical tools inserted through small incisions into the shoulder joint. Tiny suture anchors are used to reattaching the torn tendon to the bone.

2. Open tendon repair. When arthroscopy is not available or in certain types of tears your surgeon may offer you open surgical repair where a larger incision to reattach the damaged tendon to the bone.

3. Tendon transfer. If the torn tendon is too damaged to be reattached to the arm bone, surgeons may decide to use a nearby tendon as a replacement. 

4. Superior capsular reconstruction. This surgery is gaining popularity these days but is it a highly skilled surgery. 

5. Shoulder replacement: This procedure replaces the ball and the socket parts of the shoulder joint with artificial parts. Shoulder replacement is preferred in advanced shoulder arthritis. However, when nothing works in massive rotator cuff injuries shoulder replacement surgery may offer relief. Shoulder replacement is of 3 types. When the glenoid is replaced with a socket and humeral head with the ball it is standard of anatomic total shoulder replacement. When the glenoid is replaced with a ball and the head is replaced with a socket it is reverse total shoulder replacement. When only a part of the joint is replaced it is called Hemi shoulder replacement. In massive rotator cuff tear/arthropathy Reverse total shoulder replacement usually offers the best pain relief and range of motion.