Repairing rotator cuffDecember 13, 2018
The shoulder is a ball and socket joint formed between the upper end of the arm bone and the shoulder blade. It is surrounded by a group of muscles called the rotator cuff; there are in all four muscles that constitute the rotator cuff group. The muscles form fibrous structures called tendons, which insert into the bone. The muscle has a very good blood supply whereas the tendons have a poor blood supply and that has implications in injury healing.
The function of the rotator cuff muscles is two fold:
Movement of the shoulder joint
Stabilization of the shoulder joint
The rotator cuff muscles glide under a bone called the acromion, which is an extension of your shoulder blade. In any population, there are broadly three variants of the acromion: a) Flat b) Curved c) Congenitally abnormal or hooked.
Abnormal acromion morphology or conditions called scapular dyskinesia can cause increased contact between the acromion and the rotator cuff, leading to tendinitis or tear.
Injuries like a fall on an outstretched hand or a fall on the shoulder can also lead to rotator cuff tears.
l Pain in the night
l Difficulty in reaching behind the back or reaching for the top shelf
Many a time, shoulder pain due to rotator cuff tears is misdiagnosed as a frozen shoulder. A frozen shoulder, per se, is an entity where there is a global restriction in shoulder movement in spite of the absence of any muscle tear or any cartilage related issues.
A rotator cuff tear has a poor tendency to heal as discussed previously because of a poor blood supply to the tendon.
Surgical repair of acute / post-injury rotator cuff tears has been shown to have excellent results and is the preferred line of treatment. Due to advances in technology, these procedures can be done through arthroscopic surgery, which restores the normal biomechanical function of the shoulder joint. With good physiotherapy and rehabilitation, individuals are able to get back to normal levels of function at the end of a certain period of time.
For rotator cuff tears that are a result of impingement or abnormal morphology of the acromion or caused by an abnormal shoulder posture, an initial trial of a non-operative treatment can be given, with careful observation of shoulder function over a period of 3 months. If there is no improvement in symptoms over a period of time, then surgical treatment is a better option.
Non-surgical treatment essentially consists of physiotherapy and rehabilitation; there is no role for medicines in rotator cuff tears other than to control the pain. Physiotherapy and rehabilitation improve the shoulder biomechanics and the intact tendons compensate for the deficient rotator cuff. However, it does not lead to a healing of rotator cuff tears. Physiotherapy and rehabilitation can improve shoulder function to a percentage of normal, but cannot entirely restore normal function and also need periodic follow up. Moreover, there’s a risk of the disease worsening in the future. Rotator cuff tears can become bigger and tendon/muscle quality can deteriorate, precluding a surgical repair.
Neglected rotator cuff tears can lead to an increase in the size of the muscle tear and destabilize the shoulder joint over a period of time in what is called cuff tear arthropathy. Individuals with these issues are not able to lift the arm above the shoulder level. Some individuals develop what is termed a pseudoparalysis where, although no paralysis is present, they are not able to move the shoulder due to deficient muscle function.
This is a very problematic issue with regard to the shoulder joint and hence some surgeons suggest a more aggressive approach in the treatment of rotator cuff tears to prevent advanced disease.
In case of massive rotator cuff tears, which are not repairable, we have two options:
In younger individuals or patients less than 60 years of age, two options are generally employed to preserve the shoulder joint:
a) Muscle transfers: Other functioning muscles around the shoulder girdle are substituted to aid the rotator cuff function.
b) Superior reconstruction, in which the patient’s tissue from thigh/allograft tissue is introduced into the joint to stabilize the shoulder and create a new rotator cuff.
These procedures can be done on selected individuals who are willing to participate in the postoperative rehabilitation programme.
In individuals above 60 years of age who have massive rotator cuff tears and presence of what is known as cuff tear arthropathy, the only surgical option that gives fair result is inverse shoulder replacement. It is called inverse because the relationship between the ball and socket part of the shoulder joint is reversed; this negates the need for a functioning rotator cuff to move the shoulder.
There are several treatment options available for management of rotator cuff tears, ranging from physiotherapy to rotator cuff repair to a shoulder replacement. The most important take-home message for these problematic issues is that neglecting a rotator cuff tear may come back to haunt you later; so it is better to be watchful and to be more aggressive with the treatment and participate
in the rehabilitation programme actively. If treated surgically at an early stage, these interventions yield excellent results.