Rotator Cuff Tears

The rotator cuff is the term used to describe the tendons (supraspinatus, infraspinatus, subscapularis and teres minor) which insert into the top of the shoulder joint. They allow movement of the shoulder.

The rotator cuff is a common cause of pain and disability – most tears involve supraspinatus but it can involve the whole rotator cuff.

The rotator cuff can be damaged by a single traumatic injury or due to repeated trauma. Most rotator cuff tears occur in patients over the age of 40 and increase with age.

Symptoms
If you have a rotator cuff tear patients experience pain on top of the shoulder which travels down the arm. Symptoms are worse on activity and high arm elevation.

Diagnosis
Diagnosis is based on symptoms, physical examination and X-Rays. An ultrasound scan is performed to provide accurate detail of the size and shape of the tear. Often the Ultrasound scan be performed at the same time as initial appointment as part of the 1 Stop Shoulder Service. This saves time waiting for the scan. The 1 Stop Shoulder Ultrasound Clinic is performed by shoulderelbowhand.

Treatment
Not everyone with a rotator cuff tear needs surgery. The initial treatment consists of rest, anti–inflammatory medication, injections and physiotherapy.

If symptoms persist despite non surgical measures, surgery can be considered.

The type of surgery depends on size, shape and the location of the tear. A decompression is usually performed to allow more room for the tendon to move.

In general there are 3 approaches available for surgical repair:

Arthroscopic Repair – Small instruments are placed through small incisions around the shoulder, and the tendon is repaired under video control. This is technically more demanding than other techniques but the recovery is quicker and has a low complication rate

Mini Open – This uses a combination of arthroscopic and open techniques

Open Surgical Repair – A traditional open incision is sometimes required for large complex tears

The type of repair performed depends on the shape and size of the tear and often the decision is made at the time of surgery. At shoulderelbowhand all types of surgery are performed so that surgery can be tailored to the type of repair required.

Incisions

Arthroscopic Repair

5mm incisions will be made in the shoulder to place instruments around the shoulder to examine all areas of the shoulder. The number of incisions depends on the type of procedure performed

Open Repair
It is common to place an arthroscope in the joint to provide more detail about the tear, and then a 7cm scar is made to the front of the shoulder.

Procedure
The gleno-humeral (shoulder) joint will be inspected first followed by the subacromial bursa and the rotator cuff. Using arthroscopic instruments soft tissue and bone will be removed to allow the tendons more room to move. The tendon will be secured to bone using anchors which are implants placed on the inside of bone with sutures attached to them to allow stitching of the tendon to bone.

Wound closure
Absorbable sutures are placed in the wounds just under the skin, combined with butterfly (paper) sutures. There are no sutures to be removed.

Dressings

Elastoplast dressings will be placed over the top of the paper stitches and an adhesive bandage over the top of this.

Immediate aftercare
A sling will be placed on the arm and it may feel numb for the rest of the day. You can go home when you feel comfortable and will be given instructions on what to do next.

The exact type of rehabilitation is decided at the end of surgery and the repair is tested in certain positions to tailor the rehabilitation to your repair. In general a sling will be required for 6 weeks and no heavy lifting for 3 months. However while in the sling gentle movement will be required.

Signs of improvement are usually noticed after about 8-12 weeks, however the overall recovery can take up to 9 months.

Risks associated with Rotator Cuff Repair
All surgical procedures have some element of risk attached. Those outlined below are the most common or most significant to be reported.

Precautions are taken against all complications:

Continued pain - 5%. In the majority of cases all the pain is removed by surgery however occasionally a small amount of pain persists

Infection - Less than 0.1%. If this is superficial a short course of antibiotics may be required, if the infection is deeper in the tissues then a washout may be required

Nerve damage - Less than 0.1%

Stiffness - 1%. The shoulder will often become stiff after surgery and this usually settles with time and physiotherapy. Very occasionally the shoulder can become very stiff and require further procedures

Failure - of the tendon to heal to bone – This occurs in 5-10% of cases and is more common in large tears and long standing tears. Even if the tendon does not heal the pain around the shoulder is often improved