Rotator Cuff Tears
Tears of the rotator cuff are a very common cause of shoulder pain, particularly becoming more common as we age. The rotator cuff consists of 4 muscles with their tendons that surround the top part of the shoulder joint. The four muscles are called:
- Teres minor
Their function is to assist in lifting the arm forward and sideways. The majority of tears in the rotator cuff are within the supraspinatus tendon, but more extensive tears can involve the other tendons as well.
Causes of Rotator Cuff Tears
Rotator cuff tears are very uncommon in people under the age of 40 and they become increasingly common in people when they reach the age of 70 to 80. The most frequent cause of the tear is age related degeneration. A fall onto the point of a shoulder, or onto an outstretched hand can also cause a tear. They are also more commonly seen in people who repetitively use their arm above head height, and this would include tradesmen and sports people such as tennis players or swimmers.
Pain in the shoulder region is the predominant symptom, but often radiates into the upper arm. It can come on gradually or sometimes suddenly after unaccustomed activity or an injury. The pain can sometimes be more noticeable at night, and can be associated with a feeling of weakness in the arm.
The diagnosis of rotator cuff tear is based on the patients history, clinical examination and special tests. The special tests include plain x-rays, ultrasound and MRI scan. It is important that plain x-rays be performed as they may demonstrate an acromial spur. These spurs can cause an impingement syndrome and the spur can rub against the supraspinatus tendon causing it to tear prematurely.
Ultrasounds are a relatively inexpensive way of demonstrating whether there is a tear within the rotator cuff, however they are very dependant on the ultrasonographer performing the test and it is not uncommon for them to be inaccurate.
The MRI scan is the state of the art investigation for rotator cuff tears, and can demonstrate whether the tear is partial or full thickness. This can also give an idea as to whether the tear is surgically repairable.
In many cases patients can be treated conservatively. Conservative options include:
- Rest and modification of activities
- Simple pain killers and anti-inflammatory medication
- Steroid injection around the rotator cuff tendons
- Strengthening exercises
It is worth noting that many patients have rotator cuff tears which are asymptomatic. In many patients symptoms will settle spontaneously over several months, particularly with the above measures.
Surgery For Rotator Cuff Tears
If conservative treatment fails to relieve the symptoms, then surgical repair of the rotator cuff may be required. This is particularly the case if the pain is severe and/or waking you at night. In addition, if you are unable to return to your normal employment or major leisure activity, then repair of the tendon may well allow you to return to employment or leisure pursuits. Mr Dunin will explain the nature of the surgery required. There are a number of surgical approaches that can be used and include the following:
Arthroscopic Repair: This is applicable for small tears in the rotator cuff tendon and involves the use of a fibreoptic telescope placed into the shoulder and combined with several small incisions. Arthroscopic removal of the acromial spur (acromioplasty) can be performed at the same time. The advantages of this procedure are that it allows for a quicker recovery than open methods.
Mini Open Repair: An arthroscopic acromioplasty combined with a small incision to repair the torn tendon is applicable for small to medium sized full thickness tears.
Open Surgical Repair: A fully open repair is sometimes performed where the tear is large to massive. It involves making a large split in the deltoid muscle to achieve sufficient exposure to repair the torn tendons. It often requires a longer rehabilitation period to allow healing of not only the rotator cuff tear, but also of the deltoid muscle.
The decision to use the different approaches will depend on many factors, but largely related to the extent of the rotator cuff tear.
At the time of shoulder surgery a small tube will be inserted into the wound. This is attached to a pump containing local anaesthetic. In addition to regular analgesics this should keep the pain under control in the initial postoperative period. This will be attached to a pump which will reduce the pain levels in the first 1 to 2 days. It will be removed before you are discharged. You will be discharged in a sling and given some simple exercises to do. Most patients go home on the first postoperative day, but sometimes an extra day or two is required depending upon your requirements for pain relief. You will be reviewed in the consulting rooms at 2 weeks post surgery to remove sutures, and once again be given further exercises. In the majority of cases patients are sent for a course of physiotherapy. It is important during the first 6 weeks that active elevation and abduction is avoided. It takes at least 12 weeks for the rotator cuff tendon to heal back to bone. If active movements are commenced prematurely then there is a much higher chance that the rotator cuff tendon will not heal.
It is usual for patients to take several months to recover from rotator cuff surgery. It is quite common to have significant stiffness and some degree of pain for 2 to 3 months after surgery, however most patients consider the surgery to be very successful in the long run in relieving their pain and weakness.
Following the surgical procedure there is a small risk of complications that would include:
PAIN: Ongoing pain and in some patients persistent pain can be an ongoing problem despite a technically successful repair
WOUND INFECTION: This can occur following any surgical procedure. If you develop a fever, severe pain, or wound redness following your surgery please do not hesitate to contact the clinic.
SHOULDER STIFFNESS: 5 to 10% patients find that following rotator cuff surgery they develop stiffness in the shoulder of a significant degree. Given time most cases resolve but there is a small chance of ongoing permanent stiffness following this form of surgery.