Rotator cuff tear

Rotator cuff tear

Rotator cuff is an envelop of muscle tendon unit originating from the shoulder blade (scapula), holding the ball shaped head of humerus (arm bone) to the glenoid (socket of shoulder blade). Its function is to stabilize and bring about movements of the shoulder joint. 4 muscles – Supraspinatus, Infraspinatus, Teres minor and the Subscapularis insert through their tendons onto the head of humerus forming the rotator cuff.

The rotator cuff is primarily responsible for movements of abduction (elevating the arm from the side), internal rotation (rotating arm & touching the hand to back) and external rotation (outward rotation of the arm)

What causes the rotator cuff to tear?

The tear may be following a sudden jerk to the shoulder (traumatic).
It may be due to repeated overloading (as in sports) of the rotator cuff tissues resulting in tears over a prolonged period of time.
Bony impingements (from surrounding/underlying bone) over the cuff can result in fraying and tear of the rotator cuff.
Age related degeneration may cause the tissue to be less resilient to loads and can result in a tear. This is common in diabetic individuals.
A rotator cuff disease causes inflammation (tendonitis) of the rotator cuff tendons, which results in swelling and weakening of the rotator cuff tissue. This may progress to a tear over time if not attended to and treated adequately.

What are the symptoms of rotator cuff tear?

In a traumatic tear the symptoms appear immediately. In a rotator cuff disease, the pathology & symptoms develop gradually over months.
Symptoms start with occasional pain in the shoulder aggravated by elevation of the arm. This progresses to persistent pain in activities of daily living, which increases in sleep and lying down. One may start to lose strength in the arm and later find it difficult or even unable to lift ones arm over the shoulder. If neglected, it can further progress to stiffness of the shoulder.

Does rotator cuff disease need immediate attention?

It is advisable that one attends to the symptoms at the earliest, before they become severe.
It is less likely that the symptoms resolve to normal without appropriate management. Usually the disease progresses in severity if left unattended.
If diagnosed in it’s early stages, the treatment can be non surgical.
When the disease has progressed to a stage of rotator cuff tear, usually the treatment would be surgical.
If the tear is neglected over a prolonged period, a surgical repair may not be possible in some situations. The condition can worsen to a stage where a joint preservation procedure may not be possible and one may need to replace the shoulder with an artificial joint to restore a feeling of normalcy.

What investigations are necessary for diagnosis?

Plain X-rays are helpful for screening the region. They cannot give a complete diagnosis.

MRI or a USG of the region is necessary for a precise and complete diagnosis

What is the treatment for rotator cuff disease?

Depending on the stage and extent of the disease, the plan of management needs to be customized.

In early stages, it is more likely that the management is non-invasive/non-surgical. As the stage progresses to tear, a surgical management is required.

The treatment can therefore vary from activity modifications to physiotherapy, injections, arthroscopic procedures to mini-open or open surgical procedures.

Rotator cuff tears requiring repairs are treated arthroscopic through key-hole incisions. The surgery is minimally-invasive and a single day procedure.
Special arthroscopic repair specific equipment is used for the surgery. Unique suturing devices called ‘anchors’ are necessary to carry out these repairs. The techniques for repair vary depending on the type and extent of tears.

In some cases, tears which are long standing may be irreparable. A ‘joint preservation’ procedure like graft (an external tissue substitute) augmentation/ reconstruction may be necessary to salvage the joint and avoid a joint replacement. Procedures like ‘superior capsular reconstruction’ or a bridging reconstruction may be necessary.

Rarely a mini-open surgical repair may be preferred to an arthroscopic repair.

What is the prognosis of treatment?

A number of patient factors, cause & stage of disease, type and extent of pathology and the treatment modality itself decides the prognosis.

In general if the disease is treated early, the prognosis is excellent and one returns back to absolute normal. Longer the delay in treatment, the quality of results are likely to be compromised.

How is the recovery following surgery?

A timely performed arthroscopic procedure is likely to give a faster and better recovery than an open surgical procedure.
The rehabilitation is customized to every patient, depending on the intra-operative findings and the procedure performed.
An arthroscopic procedure can be either day-care or may require 1 day hospitalization.
Sutures are removed by 10 days.
Shoulder is in a shoulder brace for 3 weeks.
Full range of motion can be achieved by 2 months (depending on severity)
Return to activities of daily living by 1 month
Return to sports by 3-6 months (depending on severity)