Rotator Cuff Tears

Most tears occur in the supraspinatus muscle, but other parts of the cuff may be involved.

Anatomy
The rotator cuff is a group of four tendons that surround the shoulder joint. The four muscles of the cuff (supraspinatus, infraspinatus, subscapularis, and teres minor muscles) arise from the scapula and blend together to form a single tendon unit. The unit is attached to the upper humerus. These muscles form a cover around the head of the humerus. The rotator cuff holds the humerus in place in the shoulder joint and enables the arm to rotate.

Other structures of the shoulder that impact upon the rotator cuff include the acromion (the bony point of the shoulder) and the acromioclavicular joint (ACJ-the joint between the collar bone/clavicle and the acromion). In good health, there is just sufficient room for the rotator cuff tendons to pass under the acromion bone of our shoulder when we elevate our arm. Tears can occur in the rotator cuff as a result of disease, wear and tear, trauma and aging.

As the tendon swells due to loss of vascularity with age, it starts to rub on the acromion bone. This causes swelling and inflammation of the tendon. Years of repeat rubbing of this swollen tendon may eventually tear the tendon. It is also more likely to tear with minor strains and injuries due to its weakened state.

Symptoms
The signs and symptoms of a rotator cuff tear depend on the size and extent of the tear and the length of time that it has been present. In most cases, pain is the predominant feature. This occurs because of inflammation around the damaged tendon, as well as mechanical catching of the tendon in its tunnel under the acromion.

Weakness, associated loss of power and movement all occur, depending on the size of the tear. The pain occurs with use of the arm, particularly elevation to and above shoulder height. Pain also occurs at night, which is particularly disabling because of the interference with sleep.

Once the rotator cuff tears, it does not heal, and surgery will be necessary to repair the tendon. If extensive tears are not treated, the result is deteriorating shoulder function, the onset of widespread arthritis in the shoulder region, and increasing pain over time.

Non-operative Treatment
Surgical treatment is not necessary if pain and loss of function are not significant problems.

In many instances, non-operative treatment can provide pain relief and can improve the function of the shoulder.

Non-operative treatment options may include:

• Rest and limited overhead activity
• Anti-inflammatory medication or other analgesics
• Steroid injection (particularly in the early stages)
• Physiotherapy to strengthen the rotator cuff muscles without aggravating the problem

Operative Treatment
Arthroscopic Acromioplasty, Acromioclavicular Joint Arthroplasty and Rotator Cuff Repair
Repair of the rotator cuff tear is indicated for disabling chronic pain and loss of function. Age is not a contra-indication, and it can be performed with a low risk and morbidity, even in the elderly.

Surgery to repair a tear involves removing the roof of the tendon tunnel (acromioplasty) to make room for the tendon, removing the joint between the clavicle and the acromion (acromioclavicular joint arthroplasty), and repairing the torn tendon. The Acromial and ACJ surgery is an arthroscopic procedure which is a minimally invasive technique. This involves the use of a small telescope and miniaturised surgical instruments in the shoulder joint through small incisions.

To repair the rotator cuff tear, a larger skin incision will be made. The cuff will be secured to the bone by a series of anchors with attached sutures, or suturing the tendon by sutures through bone. Whilst this is extensive surgery, the majority of cases can be done as a day surgical procedure.

In some cases, the tear is too extensive, and the tendons have retracted to such an extent that they cannot be repaired.

Irreparable Rotator Cuff Tear
Options
Sometimes pain is not severe and no treatment may be an option in the elderly. Arthroscopic debridement and removal of Biceps Tendon will suffice in some. Arthroscopic excision of the suprascapular nerve relieves pain but does not improve function; however is often a satisfactory solution.

Transfer of Latissimus Dorsi
This procedure involves transferring another tendon to replace the rotator cuff tendons. This is a good procedure in younger patients. This results in good pain relief and function to shoulder height but not above.

Reverse Shoulder Arthroplasty
The Reverse Shoulder Prosthesis is mainly used as a last resort option for older patients with rotator cuff tear arthropathy (end stage cuff tear arthropathy) a medical condition in which the rotator cuff muscles (the muscles around the shoulder joint) have degenerated, or weakened to a point where they can no longer hold the shoulder joint intact or allow it to function normally in conjunction with arthritis.

In many cases, the causes of the weakness may be arthritis, a previous shoulder injury such as a shoulder fracture, rotator cuff tear and/or failed previous shoulder surgeries.

This procedure can also be used in revision surgery, for failed shoulder replacement and shoulder fractures.

Post-Operative Treatment
Following surgery, you will have a dressing over your incision and your arm will be placed in a shoulder sling so that the repaired tendons can heal. Depending on the size of the tear and the security of the repair, this may be a simple shoulder sling immobiliser (small tears), or an abduction brace that holds the arm away from the body, for larger tear repairs.

The day after surgery, you may have an appointment to visit the rooms or be phoned by Dr Mansfield. Your dressing can be changed to bandaids or similar waterproof dressings. If you have had a Duoderm dressing applied by us or from the hospital, it can stay on for about 10 days. Expect to see a small amount of fluid collect under the dressing. This is normal and part of the healing process. The wound sutures are absorbable and subcutaneous (under the skin), so do not need to be removed.

If you have an abduction brace, it will need to be worn for six weeks to maintain relaxation of the tendon repair and allow for its solid healing.

The repair with anchors and sutures through bone is secure. Some stress is necessary for solid healing. The sling / brace is worn for comfort and protection but may be removed for range of motion exercises, swimming pool activities and showering. You may rest your arm on a pillow, whilst out of the brace, if more comfortable.

It is particularly safer for you to wear the sling / brace at night.

When you no longer need to wear the shoulder brace (6 weeks after surgery), mobilisation and strengthening exercises commence. It takes an average of four months until useful function is regained in the arm. This can usually be achieved following a self-directed exercise program; however physiotherapy may occasionally be indicated.

The swimming pool is the ideal rehabilitation medium.

Recovery from rotator cuff tendon surgery depends on the size of the tear. For a small tear, recovery can take three months; a large tear can take up to six months. The success of repairs in terms of improving function and relieving pain is reliably in the 90% range.

Risks/Complications
Possible risks of this surgery include:

• Failure of the surgery to treat the condition
• Infection of skin wounds or shoulder joint
• Prolonged pain or stiffness of the shoulder joint

Manipulation of the shoulder under anaesthetic may be necessary to help relieve this. This is necessary in 10% of patients.

Please contact Dr Mansfield with any problems of questions that you may have related to your condition or surgery.