DESCRIPTION AND SYMPTOMS
WHAT IS THE SHOULDER’S ROTATOR CUFF?
The rotator cuff is a group of muscles (supraspinatus, infraspinatus, subscapularis, and teres minor) that are located around the head of the humerus.
Its injury is more frequent in patients older than 60, as its cause is an intrinsic degenerative process of the tendon (tendinosis).
Rotator cuff tendinosis has the following characteristics:
- It is frequently suffered by people whose jobs or sports activities require a series of repetitive movements above the head such as painters or tennis players, being a risk that increases with age.
- Patients who smoke tend to have a worse prognosis, especially those who undergo surgery.
- The spectrum of problems that can appear in a shoulder cuff injury ranges from a tendinosis without associated rupture through partial tendon injuries to massive injuries that result in shoulder osteoarthritis. For this reason, the evaluation by the specialist is very important to determine the severity of the injury.
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Rotator Cuff tears can happen in two ways:
- A sharp or sudden tear that occurs when a person falls onto their arm while stretching; or after a sudden movement while trying to lift a heavy object.
- A chronic tendon tear that occurs slowly over time. It is more likely to happen to people who are already suffering from chronic tendinosis (the tendon “wears out” until, eventually, it breaks).
There are three levels of Rotator Cuff tears:
- A partial tear occurs when the tendon does not completely break free from the bone.
- A complete or total tear is the rupture of the entire tendon. The tear size itself can vary, sometimes being as small as the tip of a pin and other times being large enough to involve the entire tendon.
- A massive rupture is when more than one affected tendon is seen. In this case, over time and if the injury worsens, the patient may suffer from shoulder osteoarthritis.
To assess the extent of the rotator cuff injury, a thorough shoulder examination is required, including evaluation by means of an x-ray and, sometimes, an MRI.
Other shoulder injuries:
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WHAT ARE THE SYMPTOMS OF A ROTATOR CUFF INJURY?
Pain when lifting heavy objects over time.- Decreased mobility.
- Disturbance in sleeping patterns or ability due to pain.
Pain when lifting heavy objects over time.IF THE INJURY IS NOT TREATED IN TIME
If a rotator cuff injury is not treated in time, the consequences can increase and affect all areas of life:
Work
Wear and tear can lead to shoulder pain and weakness. If your work requires strength or lifting, it will make it impossible for you to carry out the working day properly.
Sport
When pain occurs while doing sport, it is necessary to be evaluated by a specialist. Left untreated, total tendon tears can occur.
Loss of Movement
Without treatment, tears can get worse and the patient may lose mobility and strength in the shoulder area, which translates into not being able to carry out normal daily actions.
TREATMENT
HOW IS A ROTATOR CUFF INJURY TREATED?
There are two types of treatment: conservative treatment and surgical treatment. Depending on the type of injury the patient has and their functional needs, one or another treatment is advised.
Conservative treatment is based on physiotherapy focusing on strength gain of both the core and the shoulder girdle, but it’s also very important to reduce pain with analgesic therapy (local cold ionotphoresis, laser, etc), provided by the physiotherapist, during this time.
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Sometimes it is necessary to complement the treatment with injections in order to improve pain control so that the patient can perform the needed physical therapy exercises.
HOW IS AN ARTHROSCOPIC SURGURY TO TREAT ROTATOR CUFF INJURIES PERFORMED?
In cases where the rotator cuff cannot be repaired with conservative treatments, the patient must undergo surgery. It is very important that the patient knows the characteristics of his injury; the number of tendons affected, the degree of rupture (partial or complete), the degree of retraction (how far apart are the “ends” of the ruptured tendon), the state of the muscle (whether or not there is atrophy) and the state of the joint (whether or not there is osteoarthritis).
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This information will determine the type of treatment to be performed. There are some tears that cannot be repaired by arthroscopy and will require other treatments (such as prostheses, transpositions, etc). In the cases where the tear is repairable, an arthroscopic repair of the cuff is performed, consisting of a minimally invasive surgery in which we sew the tendon to repair the tear.
The surgeon will repair the rotator cuff as follows:
- Once the patient has been anesthetized with general anesthesia in conjunction with an arm block (see shoulder arthroscopy block for more information), between four and five 5mm incisions are made on the periphery of the shoulder, enough to view and repair the rotator cuff tear.
- A camera, or arthroscope, is inserted into the joint to identify the tear. Then a bursectomy is performed (a bursectomy is the removal of the subacromial bursa in order to be able to properly see and identify the tear).
- Proper mobility of the rotator will next be verified in order to be able to make a tension-free suture. Only after this will anchors be positioned in the humerus head, and the stitches completed. The size of the break determines the number of harpoons required.
If you would like to see an animation on how arthroscopic surgery to treat rotator cuff injuries is performed, see:
https://www.arthrex.com/es/recursos/animacion/sjjbs_kEEeCRTQBQVoRHOw/speedbridge-repair
FREQUENTLY ASKED QUESTIONS
How long does arthroscopic surgery to treat rotator cuff injuries take?
Duration time varies depending on factors such as the type of injury being treated and the characteristics of the patient. The average time is usually between 45 and 120 minutes.
What is the recovery like after an arthroscopic surgery to treat rotator cuff injuries?
- After surgery, the shoulder should remain immobilized for 4-6 weeks.
- Specialized rehabilitation of the shoulder should begin just after the operation, following a precise physiotherapy procedure. Active shoulder rehabilitation will not start until the sixth week after surgical intervention.
- The average time to resume some activities are the following: daily activities (showering, brushing teeth, etc): 4 weeks. Driving: 8-10 weeks. Using your arm for overhead activities: 12 weeks. Carrying heavy objects: 12 weeks. Sports activities involving the shoulder: 4 -6 months.
What are the possible complications from an arthroscopic surgery for rotator cuff injuries?
- Stiffness after arthroscopic surgery is possible if a good rehabilitation treatment is not performed after surgery
- There is a risk of re-rupture of the tendon or that the tendon will not heal properly (the absence of scarring) and therefore will not work correctly. The risk of both is higher in patients who smoke.
REFERENCES
Thorsness R, Romeo A Massive Rotator Cuff Tears: Trends in Surgical Management. Orthopedics. 2016 May 1;39(3):145-51. doi: 10.3928/01477447-20160503-07.PMID: 27214881
Doiron-Cadrin P, Lafrance S, Saulnier M, Cournoyer É, Roy JS, Dyer JO, Frémont P, Dionne C, MacDermid JC, Tousignant M, Rochette A, Lowry V, Bureau NJ, Lamontagne M, Coutu MF, Lavigne P, Desmeules F.Arch Shoulder Rotator Cuff Disorders: A Systematic Review of Clinical Practice Guidelines and Semantic Analyses of Recommendations. Phys Med Rehabil. 2020 Jan 31:S0003-9993(20)30030-7. doi: o10.1016/j.apmr.2019.12.017. Online ahead of print.PMID: 32007452
Fu X, Yung PS, Ma CC, Leong HT Scapular Kinematics in Athletes With and Without Rotator Cuff Tendinopathy: A Systematic Review.J Sport Rehabil. 2019 Dec 22:1-10. doi: 10.1123/jsr.2019-0095. Online ahead of print.PMID: 31869815
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